Laserfiche WebLink
-f --GCVO <br /> UNDERGROUND STORAGE TANK UNAUTHORIZE LEASE(LEd) dONTAMlt#ftK§ijT !� <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOAtOCAL`AGENCY USE ONLY -77 <br /> REPORT BEEN FILED 7 <br /> YES NO YES [ NO IHERMCE"FI!THAT}HAYE'AISTRBUTEQTHIS" lNGTO <br /> REPORT DATE A TIONS TI�WSTAUCiIDN SHEET ON THE BACK PAGE OF Fm <br /> c.;s <br /> SWED <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURETURE <br /> <N a c (moi - Z <br /> w REPRESENTING CQpIPANY OR AGENCY NAME <br /> ❑ OWNERlOPERATOR ❑ REGIONAL BOARD S. _ j 1 /� <br /> R t LOCAL AGENCY ❑ OTHER � Pr�S eL Lo <br /> cc ADDRESS <br /> ( j��J <br /> 1. •0- l�O/`x <br /> 34?� STREET Chq S�l SiATECA 21P <br /> Lu NAME CONTACTPERSON PHONE <br /> m <br /> Z¢ at� ❑UNKNOWN ( ) <br /> a a ADDRESS (/� 7D <br /> - <br /> � Cox V STREET gry�L"�/�C"�� <br /> FAC LITY NAME(IF APPLICABLE} OPERATOR /PHONE <br /> ODfR'ES A'/ <br />' / / M • STREET O.S//• ! C', <br /> w CROSS STREET <br /> O LOCAL AGENCY AGENCY NAME CON ACT PERSON PHONE <br /> w w REGIONAL BOARD PHONE <br /> a0 <br /> (1) NAME QUANTITY LOST(GALLONS( <br /> uJ <br /> Q <br /> CJ UNKNOWN <br /> O <br /> mz <br /> �Z <br /> N ❑ <br /> UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> w vµ b MI v o �i Y1 Es TANK TEST TANK REMOVAL ❑ OTHER <br /> F� <br /> 'Z <br /> DATE DISCHARGE BEGAN MEMO USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN ❑REMOVE CONTENTS CLOSE TANK 6 REMOVE ❑REPAIR PIPING <br /> LmuM b Y Y <br /> o HAS DISCHARGE BEEN STOPPED 7 a REPAIR TANK ❑CLOSE TANK&FILL IN PLACE a CHANGE PROCEDURE <br /> o YES ❑ NO IFYES,DATE 0OY j J ❑REPLACE TANK ❑OTHER <br /> Y <br /> -B SOURCE OF DISCHARGE CAUSE(S) <br /> Q ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br />! v ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> Lu w CHECK ONE ONLY <br /> w+a <br /> U ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER •(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> HEC ONE ONLY <br /> Z NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> Q <br /> D y ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE E DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> J (SEE BACK FM WTM.M <br /> a Z ❑ <br /> F3- CAP SITE(CD) F7EXCAVATE 5 TREAT(ET) ❑ PUMP A TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACTIVE) ❑ OTHER(OT) <br /> Z <br /> 0 <br /> a <br /> U <br /> HSC OS(&W <br />