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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 /> REPORT BEEN FILED 7 I HEREBY CERTIFY THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> ❑YES NO ❑YES LyZ1NO REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 251807 OF <br /> THE HEALTH AND SAFTY CODE. <br /> REPORT TE CASE♦ <br /> GATE <br /> M M Y Y SIGNED <br /> NAME OF NDIVIDUAL FILING REPORT PHONE SIGN <br /> m ❑ COMPANY OR AGENCY NAME <br /> REP SENTING ❑ OWNERIOPERATOR REGIONAL BOARD �. <br /> x LOCAL AGENCY ❑ O/T/H/E�R j^jy�(J o b j l <br /> ADD <br /> SS <br /> 7E/SS�/�^ C CONTACTPERSON PHONE"' Q <br /> use- UNKNOWN /V V ( �.11 Olp(�,?- <br /> ¢<y ADDRESS /,r � c � <br /> 2,WD L. P �IAA) �T ET• 51117E <br /> FACILITY NAME.IF <br /> APPPPLICABLE)� ) OPERATOR PHONE <br /> DRESSK-V ��VS-//"-r JLJ y ��y(Gv/J �O�l <br /> 8 s' �Cii1�^ ..` �m H✓ <br /> cm � u n <br /> y ROSSSTREET sr� TYPEOFAREA MERCIAL E]INDUSTRIAL❑RURAL TYPE OF BUSINESS RETAILFUEL STATION <br /> ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> LOCALAGENCY AGENCY NAME OONTACTPERSON PHONE <br /> SBI REGIONAL BOARD PHONE <br /> i ( <br /> (t) NAME QUANTITY LOST(GALLONS) <br /> UNKNOWN <br /> N ❑ UNKNOWN <br /> i DATE DI RED /y� /, HOWDISCOVERED E::] INVENTORY CONTROL ❑ SUBSURFACEMONITORING ❑ NUISANCECON)ITIONS <br /> OM M D S D /YV Y E:] TANK TEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THATAPPLY) <br /> UNKNOWN REMOVE CONTENTS ❑ REPLACETANK O CLOSETANK <br /> y M M D Y V <br /> Q HAS DISCHARGE BEENSTOPPED <br /> DATE M D �Y �- R�L)Y REPAIR,T(AJNK O [EPAIR PPWG O CHANGEPROCEDURE <br /> O <br /> ❑ OTHEz� „/[CJ(i)aL <br /> SOURCE OF DISCHARG,E�, T/JATANKSOONLY/CAPACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK {{\I UNKNOWN /D16Z Y-� L EDGAFIBERGLASS ❑ OVERFILL ❑ RUPTUREFAILURE <br /> F-1PIPING LEAK `\ AGE YRS ggSTEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER 5.KWNOWN ❑ OTHER ❑ SPILL O OTHE <br /> CHECKONEONLY <br /> ❑ UNDETERMINED � SOILONLY ❑ GROUNDWATER ❑ DRINKINGWATER- (CHECKONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECKONEONLY <br /> ¢< ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEAMIP COMPLETEDOR UNNECESSARI) <br /> tiq ❑ NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEEDO EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 3 ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> 2551 ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY IRS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> � Sri' �?9ScsS� i�7/I rec� UAA^L mow; - <br /> f� rr�r7Cz.t`� a� <br />