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UNDERGROUND STORAGE"TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br /> EMERGENCY / HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> �U( REPORT BEEN FILED 7 ❑YES ❑ NO I HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> ❑ YES NO <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT DATE � CASE i <br /> O `l <br /> M Y SIGNED DATE <br /> m NAME OF INDIVIDUALG SPORT �( a Pp4q ) Lfw-3"Cl HONESIGNATURE <br /> w REPflESE G ❑ REGIONAL BOARD COMPANY OR AGENCY NAME /J r I I C S <br /> RA]PEIATOR ❑ ^ l pak Service <br /> m LOCAL AGENCY ❑ OTHER Jam" lr n yy�p�� IJ1$IDY\ <br /> S <br /> A DRESS nl O, [Z�../ O � -fes Wi ` Ifs----lb I <br /> Dm were ra <br /> smela <br /> w NAME CONTACT PERSON PHONE <br /> Fa FrcCn [� �. (� ❑ UNKNOWN <br /> z <br /> n< ADDRESS T � /' /� el <br /> Cn (/jr\ <br /> w a CJ 0. LJT (Ji r 11 <br /> m <br /> srReer crtY srAre <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE f <br /> ADDRESS Cj Lo IL �oeQr I� <br /> J V NYY <br /> y CROSS STREET <br /> CY AGENCY <br /> z U LJC<n N`-+H�+q(/0. i V� C.L IA iI NAME <br /> CONTACT PERSON n a . 1 X0'8-34Y <br /> REG <br /> ,z <br /> PHONE <br /> & ^ <br /> m (1) NAME QUANTITY LOST(GALLONS) <br /> rL U � ' UNKNOWN <br /> m ❑ UNKNOWN <br /> i DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDTIONS <br /> 6 Y ❑ TANK TEST ❑ TANK REMOVAL OTHER Sa Cly (�VQs�I <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> m <br /> UNKNOWN ❑REMOVE CONTENTS CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> w M D Y Y <br /> p HAS DISCHARGE BEEN STOPPED 7 (� ❑REPAIR TANK CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> mo YES ❑ NO IFYES,DATE lM l a Y ❑REPLACE TANK ❑ OTHER <br /> URCE OF DISCHARGE M CAUSE(S) <br /> ja 'TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> OO ❑ PIPING LEAK ❑ OTHER ❑ CORROSION JD&UNKNOWN ❑ OTHER <br /> H ww CHE ONE ONLY <br /> U UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CH CK EONLY <br /> zm NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> jy ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> J ISHera wxoflival <br /> 00 ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER IGT) REPLACE SUPPLY IRS) <br /> wa ❑ CONTAINMENT 13ARRIER(C8) ❑ NOACTION REQUIRED INA) ❑ TREATMENTAT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> m ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> S"Je-$+L5 a-t A-Yl a.� ra+Y\ed o�-t B v� o 44,4- S r+2 1S �e r.�.(VL _' <br /> w O <br /> 8 <br /> N9Cm1AaR <br />