Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENCY USE ONLY <br /> a YES NO REPORT BEEN FILED? YES .�I �^' 1HEREBY CERTIFY TEAT 1 AM A pES1GNA7Ep QVEfiNMENi EMPLOYEE.ANOTHAT.t HAVE <br /> REPORTED'THIS WFORMATIONJO LOCAL KS TQ SEC?fON 251..947 OF;. <br /> REPORT DATE J��y 2J CASE* <br /> QTHE HEALTH ANp CODE ` <br /> OMIL-2 M O D V D Y V SKNED <br /> NAME FI /IVI/ DL FILING REPORT 0�6�� PHO ) 38a_�w SIGN1e` f <br /> 0 REPRESENTING OWNER/OPERATOR REGIONAL BOARD COMPANY OR AGENCY NAME <br /> 0 LOCAL AGENCY OTHER <br /> O <br /> a <br /> ¢ ADDRESS <br /> J <br /> STATE /V21P�v <br /> w NAME y��J CONTACT PERSON (P�HJO//N�►E j (� C�� <br /> J / / l v� n UNKNOWN Fi ,06) 39 -5;N3 <br /> m� <br /> U) <br /> Z <br /> Qa ADDRES///$J Lam///�n <br /> tr <br /> /W /`ifJ V`��/ G (�I / CRY 72 ��/, Q STATE <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ADDRESS <br /> Lu (Y v_ - �� STRW2 � CRY ice' , `- C..COATV �' P <br /> F6 CR SS STREET TYPE OF AREA COMMERCIAL a INDUSTRIAL UR TYPE OF BUSINESS TAIL FUELSTATION <br /> �((/ RESIDENTIAL a OTHER 0 FARM D OTHER <br /> LOCALAGENCY ^ ?AGENCY NAME CONTAC PERSON PHONE <br /> co <br /> W <br /> w REGIONAL BOARD PHONE <br /> (�) NAME QUANTITY LOST(GALLONS) <br /> LU <br /> UNKNOWN <br /> w 1 ��,� <br /> ~0 (2) <br /> UNKNOWN <br /> z <br /> DATEDISCOVERED /� HOW DISCOVERED INVENTORY CONTROL 0 SUBSURFACE M-OfLIITTORING F NUISANCE CONDITIONS <br /> w M M / D v D r 0 TANK TEST TANK REMOVAL OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> YUNKNOWN REMOVE CONTENTS REPLACE TANK CLOSE TANK <br /> W M M D D Y Y <br /> p HAS DISCHARGE;11EENJ S ED? ��yREPAIR TANK REPAIR PIPING CHANGE PROCEDURE <br /> pYES O IFYEy ES,DATE M M D D y OTHER 4 G✓ 14 4 � <br /> Lu <br /> SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> F-1 TANK LEAKUNKNOWN GAL, FIBERGLASS OVERFILL RUPTURE/FAILURE <br /> Er F-1 PIPING LEAK AGE YRS F7STEEL El CORROSION [� NKNOWN <br /> OTHER 0 UNKNOWN OTHER D SPILL E�j OTHER <br /> L,w CHECK ONE ONLY <br /> IL <br /> 0 UNDETERMINED SOIL ONLY GROUNDWATER DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE Y <br /> Z N <br /> Q a SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) a CLEANUP IN PROGRESS 0 SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> U N NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS NO FUNDS AVAILABLE TO PROCEED VALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 4z ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) ENHANCED BIODEGRADATION(IT) <br /> 00 <br /> w� ❑ CONTAINMENT BARRIER(CB) O EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> 2 <br /> TREATMENT AT HOOKUP(HU) F7 NO ACTION REQUIRED(NA) OTHER(Ol) <br /> c <br /> z l f j <br /> c✓ (JL ,v/•� o�� .�r cc F E B 11 1993 <br /> PERMIT/SERVIC""&n <br />