HomeMy WebLinkAboutRELEASE REPORT 11/3/2015UNDERGROUND STORAGE TANK (UST) SITE - UNAUTHORIZED RELEASE I CONTAMINATION REPORT
EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES
FOR LOCAL AGENCY USE ONLY
❑ Yes XNo REPORT BEEN FILED? ❑ Yes �40
1 HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE
REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF
THE HEALTH AND SAFETY CODE.
REPORT DATE
CASE #
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SIGNED DATE
NAME -OF
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SIGNATURE
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REPRESENTING
COMPANY OR AGENCY NAME
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,E3:T_QCAL AGENCY ❑ REGIONAL BOARD
❑ OWNER /OPERATOR ❑ OTHER
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ADDRESS
STREET 9 ! 4 � CITY 8K.57;7 -D STATEC-'4 ZIP41 .3 90 1
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NAME
CONTACT PERSON
PHONE
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ADDRESS
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FACILITY NAME (IF APPLICABLE)
OPERATOR
PHONE
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ADDRESS
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CROSS STREET
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PHONE
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REGIONAL BOARD
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(1) NAME QUANTITY LOST (GALLONS)
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❑ Unknown
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DATE DISCOVERED
HOW DISCOVERED Tank Test Tank Removal Nuisance Conditions
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Inventory Control Subsurface ace Monitorin g Other
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DATE DISCHARGE BEGAN
METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY)
❑Remove Contents ❑ Close Tank
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Unknown
❑Repair Tank ❑Change Procedure
HAS DISCHARGE BEEN STOPPED?
❑Replace Tank Other
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❑ Yes ❑ No IF YES, DATE
❑ Repair Piping
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SOURCE OF DISCHARGE
CAUSE(S)
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❑ Tank %Piping ❑ Dispenser ❑ Delivery Problem
❑ Spill ❑ Overfill ❑ Physical /Mechanical Damage ❑ Corrosion
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❑ Submersible Turbine Pump (STP) ❑ Other
❑ Installation Problem a Unknown ❑ Other
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CHECK ONE ONLY
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%Undetermined ❑ Soil Only ❑ Groundwater ❑ Drinking Water —(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED)
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CHECK ONE ONLY
❑ Open - Site Assessment ❑ Open - Verification Monitoring
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ROpen - Assessment & Interim Remedial Action ❑ Open - Inactive
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❑ Open - Remediation ❑ Closed — No Further Action Required
CHECK APPROPRIATEACTION(S)
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Human health exposure control? ❑ Yes o ❑ Unknown
Groundwater migration control? ❑ Yes No ❑ Unknown
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2:No Action Required (NAR) ❑ Excavate & Treat (ET) ❑ Treatment at Hookup (TH) ❑ Other
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❑Excavate & Dis p ose ( ED ) ❑Free Product Removal ( FPR ) Replace Supply ( RS )
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