Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)! CONTAMINATION SITE REPORT <br /> EMERGENCYHAS STATE OFFICE OF EMERGENCY SERVICE FOR LOCAL AGENCY USE ONLY <br /> REPORT SEEN FILED 7 <br /> YES NO ❑ YES NO I HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FOA R <br /> REPORT DAT= CASE A <br /> �I �ul o ti U r v SIGNED DATE <br /> NAME OF INUIVIOUAL FILING REPORT PHONE SIGNA RE <br /> k T. s ,, 18-3LIYQ <br /> ❑ REPRESENTING ❑ COMPANY OR AGENCY E N <br /> w OWNL:RlOPERATOR ❑ REGIONAL BOARD <br /> Y �� 0 � � <br /> cr <br /> �OCALAGENCY ❑ OTHER <br /> w <br /> � [ADCRESS <br /> 3 STREEP (�J�bG� Cm {QL' OY1 �.� � e <br /> STATE ZIP <br /> J NAME CON TACT PERSON PHONE <br /> z V� ❑ UNKNOWN <br /> a d ACD;:-:SS <br /> STREET W T01 CFTY �/�I^ zip <br /> STATE (� '�1 Zip <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> (70 <br /> ~ ADDRESS <br /> U <br /> 7� gs�� <br /> Lu STREET CITY G/ p �^� <br /> cau <br /> ~ CROSS STRECOUNTY zla <br /> LOCAL AGENCY AGENCY NAME CONTACTPERSON <br /> z�! PHONE <br /> wl 55 <br /> wL) 1 <br /> a¢ REGIONAL <br /> n / <br /> BOARD PHONE <br /> l� V 1 L W C+t C 1 <br /> (11 NAME QUANTITY LOST(GALLONS) <br /> Z o /�7'l.� If! G�-�-K <br /> a � .� ���5� UNKNOWN <br /> o� (2) <br /> z <br /> h <br /> ❑ UNKNOWN <br /> �- <br /> DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> z <br /> w ] <br /> w �+� O M� I o� nl Q Yl Y:E [:] TANK TEST TANK REMOVAL ❑ OTHER <br /> 4m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> d <br /> } UNKNOWN ❑REMOVE CONTENTS CLOSE TANK&REMOVE REPAIR PIPING <br /> w <br /> u M ❑ o Y r <br /> Q HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK ❑CLOSE TANKS FILL IN PLACE ❑CHANGE PROCEDURE <br /> YES ❑ NO IF YES,DATE ' I ❑REPLACE TANK ❑ OTHER <br /> M u ❑ o Y v <br /> SOURCEDISCHARGE CAUSE(S) <br /> w <br /> a TANK LEAK ❑ UNKNOWN ❑ OVERFILLRUPTUREIFAILURE ❑ SPILL <br /> DSU ❑. PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> UJ a CHECK ON LY <br /> O UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> d O <br /> z ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> w <br /> rA <br /> j ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U y <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTICN(S) ❑ EXCAVATE 8 DISPOSE(ED) ❑ REMOVE FREE PRODUCT{FP) ❑ ENHANCED B16 DEGRADATION(IT) <br /> J fSEE WK FOR DE7A"s <br /> a ZF-] CAP SITE(CD) F--] EXCAVATE 3 TREAT(ET) ❑ PUMP d TREAT GROUNDWATER{GT)❑ REPLACE SUPPLY(RS) <br /> Li- <br /> w ❑ CONTAINMENT BARRIER(CB) 71 NO ACTION REQUIRED(NA) ❑ TRE_AT`MENT AT HOOKUP{HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) dDTHER{OT} be QtN1,/1�7 LOca I QdeS$( f <br /> qmmm <br /> z <br /> w <br /> w <br /> 0 <br /> Q <br /> U <br /> HSC 05{sw <br />