|
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT
<br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES
<br />REPORT BEEN FILED 7
<br />I YES NO I S 7 No
<br />- FOR LOCAL AGENCY USE ONLY.
<br />I HEREBY CERTIFY -THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE •
<br />DISTPIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM
<br />REPORT DATE a , i o2 9
<br />CASE s
<br />I cJ yi I yl 1 ml SIGNED DATE
<br />NAME OF INDIVIDUAL FILING REPORT ,
<br />Y . ,f
<br />PHONE
<br />‘k... Bp 1 s
<br />SIGNA RE
<br />,u 1- a
<br />REPRESENTING I I OWNER/OPERATOR [____1 REGIONAL BOARD
<br />i LOCAL AGENCY 7 OTHER
<br />COMPANY OR AGENCY NAME
<br />, , t . ib, i v H‘,/ eti66 ,/ i / 5 1
<br />3_ ..11 ct ADDRESS .
<br />0 II- t ' 1_-01 D er ---C-t:
<br />STREET
<br />S. 1-' a-r• c(-0,-, c,(4, q,5,;01,2
<br />CITY STATE ZIP I RESPONSIBLE PARTY NAME
<br />Pad. &7L 11-(-c- i 1 UNKNOWN
<br />CONTACT PERSON
<br />P -1-, S'11. C1'?_„, /1.2-"C---
<br />PHONE
<br />(.:07) %
<br />ADDRESS —J-- ,
<br />-1003, £. 60 cz.,w-d,o-c) Rd,
<br />STREET
<br />,..S../--oc /(710), C /1-.Skik
<br />CITY STATE
<br />`? -5-c24 5
<br />P SITE LOCATION _ FACILITY NAME (IF APPLICABLE) 1 ....... , OPERATOR PHONE
<br />R) t ot-e0 Cel r Fi_ -IL)t 6
<br />ADDRESS
<br />3 0 3 .. E. E
<br />L..
<br />(91 .0 C ir\I-C- i ,t•-• 9 If . _--J,3 6 5
<br />CITY COUNTY ZIP
<br />CROSS STREET i .
<br />&GI-X-1 0 ! IMPLEMENTING AGENCIES LOCAL AGENCY ,AGENCY NAME
<br />S I ", ec P H S — E rq D
<br />CONTACT PERSON
<br />t-11,1,,,b,„..„. enz-et
<br />PHONE )( -3'
<br />REGIONAL BOARD
<br />(du QC a PHONE
<br />) SUBSTANCES I INVOLVED
<br />C
<br />NAME QUANTITY LOST(GALLONS)
<br />il.
<br />
<br />
<br />X UNKNOWN
<br />sr...0.....eit:ryt__,L....,
<br />L...
<br />71 UNKNOWN DISCOVERY/ABAIEMENT 1 DATE DISCOVERED ,
<br />0 m1 ) m1 °DI 6° i 1
<br />HOW DISCOVERED I I INVENTORY CONTROL 1 1 SUBSURFACE MONITORING 7 NUISANCE CONDITIONS
<br />! TANK TEST 'TANK REMOVAL 1---I OTHER
<br />DATE DISCHARGE BEGAN
<br />L
<br />U1 m1 DI 01 Yi YI
<br />71:1 UNKNOWN
<br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY)
<br />,REMOVE CONTENTS f....QLOSE TANK & REMOVE I 1 REPAIR PIPING
<br />HAS DISCHARGE BEEN STOPPED?
<br />YES I I NO IF YES, DATE
<br />.
<br />0m1 I C (6%1 1 Y 1
<br />I I REPAIR TANK 7 CLOSE TANK & FILL IN PLACE I I CHANGE PROCEDURE
<br />I I
<br />REPLACE TANK 7 OTHER
<br />D Y Y SOURCE/ CAUSE SOUR E OF DISCHARGE
<br />L j TANK LEAK UNKNOWN
<br />[ I PIPING LEAK OTHER
<br />CAUSE(S)
<br />1 1 OVERFILL 1 1 RUPTURE/FAILURE I I SPILL
<br />1 I CORROSION .f:›15-40KNOWN I 1 OTHER
<br />Lli Lu Lr) 0_ a >-
<br />0 '"
<br />CHECK ONE ONLY
<br />, ,
<br />1 J UNDETERMINED SOIL ONLY GROUNDWATER n DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED)
<br />x
<br />CHECK ONE ONLY
<br />, z ?) NO ACTION TAKEN I I PRELIMINARY SITE ASSESSMENT 'NORKPLAN SUBMITTED L 1 POLLUTION CHARACTERIZATION
<br />Lu ,p
<br />cr 1-"1 1 I LEAK BEING CONFIRMED 1 I PRELIMINARY SITE ASSESSMENT UNDERWAY 1 POST CLEANUP MONITORING IN PROGRESS = 0, L)
<br />1 I REMEDIATION PLAN F1-1 CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY REMEDIAL I ACTION CHECK APPROPRIATE ACTION(S) EXCAVATE & DISPOSE (ED) 1 , REMOVE FREE PRODUCT (FP) I I ENHANCED BIO DEGRADATION (IT)
<br />(SEE BACK Fal DE1 MS) ..___
<br />[ i CAP SITE (CD) . I EXCAVATE & TREAT (ET) [ ! PUMP & TREAT GROUNDWATER (GT) 1 1 REPLACE SUPPLY (RS)
<br />, i , 1 VENT SOIL (VS) 1 1 CONTAINMENT BARRIER (CB) n NO ACTION REQUIRED (NA) n TREATMENT AT HOOKUP (HU)
<br />1 1 VACUUM EXTRACT (VE) ! I OTHER (OT) ICOMMENTS 4e_,) .. 1
<br />/lc
|