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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 /> F-1 VES NO E:] YES E] NO <br /> REPORT BEEN FILED? I HEREBY CERTIFYTHATI HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTIONBHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT DATE CA /'J (/LgI"y. . <br /> (/ <br /> �'-1 v Y SGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> o Z-- W,ff-3 yEI0 <br /> REPRES NG ❑ OWNERlOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> S LOCAL AGENCY ❑ OTHER A-Joa V &' (�¢G. �!q U(C{s <br /> w ADDRESS AV -aa h \ <br /> STREET Dm STATE ZIP <br /> w NAME CONTACT PERSON PHONE <br /> i J &,7 C'! L�f! CGt//-C ❑ UNKNOWN Q 411, - 77�b <br /> m i ADDRESS <br /> aie A/s le mak xv., CA 9s Z oS <br /> STREET CRY BTATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE �/ryp� <br /> ( Zc4 Z(7Y <br /> -77YD <br /> ti ADDRESS /O8Y8 Y . Co/'/veiv�o%-s /ZiL S�vc%�rsr� Cff <br /> 0 <br /> w srREET cm couxrr P <br /> y CROSS STREET <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> zy <br /> z- <br /> w <br /> ww0 REGIONAL BOARD PHONE <br /> (L) NAME OUANTITY LOST <br /> LOST( / <br /> N <br /> GALLONS <br /> OWN <br /> �i <br /> w ❑ UNKNOWN <br /> E- DATE DISCOVERED QQ'' HOW DISCOVERED ❑ VENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Y D D ( v Y ❑ TANK TEST TANK REMOVAL ❑ OTHER n.� / iPrLc Ff <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGEJ04ECk ALL THAT APPLY) <br /> a <br /> UNKNOWN ❑REMOVE CONTENTS Egl6LOSE TANK 6 REMOVE ❑REPAIR PIPING <br /> y Y D Y Y <br /> HAS DISC E BEEN STOPPED 7 E:]REPAIR TANK ❑CLOSE TANK&FILL IN PUCE ❑CHANGE PROCEDURE <br /> O <br /> YES ❑ NO IF YES.DATE <br /> Ml ol d Y Y ❑REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> y0 ❑ PIPINGL K ❑ OTHER ❑ CORROSION ❑ UNKNOWN Q OTHER <br /> ww CHECKO ONLY <br /> Q UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY <br /> zZ ❑ NOACTIONTAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> �y ❑ 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 d DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> 7MLY.7 <br /> 7 <br /> w ❑ CAP SITE(CD) ❑ EXCAVATE 8 TREAT(En ❑ PUMP 8 TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> wa E:] CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENTSOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> K �Glv�AL� Si/r aSsCss/ o.� wilJ he atnPsse, ole�n° .n . r i <br /> f eK/en / o! e�,ie .� .. evn y 5 <br /> f/ Nac oslsm <br />