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yrs I 11"P15- U3 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTA ON SIT R6 T <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES •FOR LOCAL AGENCY USE ONLY-% 1-1— 'j <br /> REPORT BEEN FILED? f. 3 ?�"'` <br /> YES ❑ NO �i YES ❑ NO THEREBY CERnFY?HATI HAVE DISTN®UTEDTHIS INFONMATION ACCORDIIGTOTHE <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SFIEET ON THE BACK PAGE OFTHIS FORM. <br /> REPORT DATE CASE (may` E�4CITi�(J(L}MEIVIP:4 'art ;F;. . - <br /> O oor3o \ SIGNED DATE <br /> OF INDIVIDUAL FILING REPORT PHONE ` SIGNATURE <br /> w REPRESENTING ❑ OWNER/O ERA ❑ REGONALBOARD COMP OR AGENCYNAME <br /> ¢ ❑ LOCAL AGENCY ❑ OTHER <br /> R CO. <br /> ¢ ADDRESS oc ,(A7 <br /> "•v J BTI�[f Nfn/ J IJ CRY IV 2� SIATE to N031 <br /> a— <br /> w NAME CONTACT PER ON PHONE <br /> i aC�ALO ❑ UNKNOWN ( ) <br /> 0 as ADDRESS <br /> 3IIIEET Vw"`� cm arAtE np <br /> FACiUlYNEE(IIFAPPL'`t.AB-L�E) OPERATOR PHONE <br /> o W�C� C6.0 aC°R� J tv I� . 7- tCNeR (Lo ) Ag-cis <br /> ADDRESS -{ <br /> w 2V S N . RREFI S 1. cm ST TON couury�aMV\lV�S�Y <br /> wCROSS STREET <br /> p LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> w REGIONAL BOARD v PHONE <br /> ` Q.e G Sie�nT�rc (9i1� Ya,S s -3oou <br /> y (1) NAME QUANTITY LOST(GALLONS) <br /> �L <br /> w �lJy7O\\TV `TO ❑ UNKNOWN <br /> m i (2) <br /> y ❑ UNKNOWN <br /> i DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CO1t�\0TONS <br /> 2 q Y ❑ TANK TEST ❑ TANK REMOVAL OTHER Y d I V <br /> DATE DISCHARGE BEGAN A METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> W O lQD -\ ❑ UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANKB REMOVE REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED T ❑REPAIR TANK ❑CLOSE TANK&FILL W PLACECHANGE PROCEDURE <br /> C YES ❑ NO IF VES.DATEa -1 Y v REPLACE TANK OTHER ��fC <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ¢j ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE SPILL <br /> wO ❑ PIPING LEAK ® OTHER%\w ROSION ❑ UNKNOWN OTHER lthmD-Ilf- <br /> h wa CHECK ONE ONLY Iwa <br /> O ❑ UNDETERMINED SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) v\ <br /> CHECK ONE ONLY <br /> zz ❑ NO ACTON TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> jy ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS f' <br /> UW <br /> ❑ REMEDIATION PUN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> Irff wr«r on+.m <br /> a 0 ❑ CAP SITE(CD) ❑ EXCAVATE A TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> t <br /> w . <br /> w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION R QUIRED(NA) ❑ TREATMENT T HOOKUP(HU) VENJ SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) OTHER(OT)uulmj� S49 <br /> Ir <br /> MO.A7'qCAz vu <br />