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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 /> ❑,ES lzd!40 REPORT BEEN FILED? El YES dMD "I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE'. <br /> 'REPORTED THIS INFORMATION.TO LOCAL OFFICIALS PURSUANT TO SECTION 251807 OF <br /> REPORT DATE <br /> �J L Q CASES THE HE2UTH AND-SyTY CODE, <br /> 10 SIGNED DATE <br /> NAME OF INDNIWAL FLING REPORT PHONE SI <br /> 1/68-3439 - <br /> G� <br /> REPRESENTIN - <br /> ❑ OWNEA/OPEMTOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> LOCAL AGENCY ❑ OTHER S,�N 1D,QQvI I,� Ca Pv�u 14"ASE,�V <br /> ADDRESS <br /> �/ �/jr sM/ /a44v1tV srrvz-"4�N c4 gSzoz._ <br /> EE Gry <br /> SATE ZP <br /> w NAME CONTACT PERSON PHONE <br /> DOkE�(J�Pi't�CvaPdNY�nl L ❑ <br /> UNKNOWN (wR)9'13- IGS I <br /> V ADDRESS <br /> -o- RDK- 3.0ow 5`mc �rnN c R6Z4D <br /> FACILITY NAME(P APPLICABLE) - OPERATOR cm STATE p <br /> PHONE <br /> s RFI Ai- tt/ti169`f co. ZINC • (trt ) �t43-/481 <br /> ADDRESS <br /> / >j E- cNAPTEt; wAr S rc�K rn�l �ua�vl rt cit 6z,v g. <br /> COUNTYm CROSS STREET ap <br /> LOCALAGENCY AGENCY NAME CONTACTPERSON prypNE <br /> Ew --;;4N co. OvBaIL j4at7N SE v/c£S fR1L_ �v£N� (zxc)�/6&3H3 <br /> REGONALBOARD <br /> PHONE <br /> (1)�TNYGf3ENLENE NAME QUANTITY LOST(GALLONS) <br /> (a xY4ENr� ❑ UWNOWN <br /> 3a TPIt ❑ UNKNOWN <br /> W DATE DISCOVERED / q HOW DISCOVERED E::] INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> 1 u1 / u O D `v 0 Y ❑ TANK TEST ❑ TAM(REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> � <br /> MI Ml D1 D1 YJ Yl lfr <br /> UNKNOWN ❑ REMOVECONTENTS ❑ REPLACETANK dCLOSE TANK <br /> 5� WAS DISCHARGE BEEN STOPPED? ❑ REPAIRTANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> F3 ❑ YES ❑ NO PYES,DATE N N DI DI Yl r ❑ OTHER <br /> O SOURCE OF DISCHARGE CAUSE(S) <br /> ❑ TANK LEAK ❑UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> O F-1PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHEq <br /> ww CHECKONEONLY <br /> ❑ UNDETERMINED d SOILONLY ❑ GROUNDWATER ❑ DRINKNGWATER- (CHECK ONLY P WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEOM.Y <br /> bZ dNO ACTION TAKEN ❑ PRELMINARY SITE ASSESSMENT WORKPLAN SUBMRTTED ❑ POLLUTION CHARACTERIZATION <br /> �q ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING N PROGRESS <br /> ❑ REMEDIATON PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUPUNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE 8 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> zp <br /> wp F­1 CAPSITE(CD) ❑ EXCAVATE TREAT(ET) ❑ f1JMP6TREATGROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> �Y ❑ CONTAINMENT BARRIER(CB) ❑ MD ACTON REQUIRED INA) ❑ TREATMENT ATHOOKUP(HU) ❑ VENTSOIL(VS) <br /> ❑ VACUUMEXTRACT(VE) � OTHER(OT) 2-e <br /> 12 FO'k`THXC4 NiiaL Qf 4Q&'i&D --ro -rt4 ),J.4TRF AN4 <br /> b f)fT)51q'r-oF cowrd.,11,44-rhon( 45 PY -INS ,�✓�/�RuPR//!TE RFG�t 4T»Ry <br /> HSC 751A2I <br />