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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVIC S FOR LOCAL AGENCY USE ONLY <br /> ❑ YES NO REPORT BEEN FILED7 ❑ YES NO 1 HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT DATE 1 9 CASE t <br /> DYu / l v SIGNED �t DATE . <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> REPRES G ❑ OWNERIOPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME � <br /> g LOCAL AGENCY ❑ OTHER n TCILe S-¢�U <br /> ¢ ADDRESS (`� <br /> YY� t1 <br /> N- Su ✓oc u A , S tElz•, C-9- <br /> 4s Z-v i <br /> STREET CITY STATE <br /> ZIP <br /> J <br /> NAME <br /> o CONTACT PERSON !� PHHONeEEQ <br /> i¢ / Gt G! C �U<n�/ c � �e�❑�NKNOWN ��[�A� J�-�cc���` ( W/1 L/�G '-/7 <br /> 6 a ADDRESS <br /> n <br /> w lOyy s. .busvv� 5�v fr/+ G� 4s <br /> ¢ <br /> STREET STATE <br /> IPP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> u ,e. �� �r s c�> ggra <br /> < ADDRESS <br /> U <br /> O <br /> ly STREET CTI ZIP <br /> y CROSS STREET <br /> g LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> W" <br /> wU <br /> w REGIONAL BOARD PHONE <br /> a <br /> y 17) NAME OUANTITY LOST(GALLONS) <br /> w <br /> NKNOWN <br /> �P m <br /> N <br /> ❑ UNKNOWN \ <br /> i DATE DISCOVER2EDy HOW DISCOVERED ❑ I -DRY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> 2 Ou O M O d/ o �Y v ❑ TANK TEBT TANK REMOVAL ❑ OTHER <br /> a DATE DISCHARGE BEGAN METHOD-USED TO STOP DISCHAR HECK ALL THAT APPLY) <br /> ¢ M D Y UNKNOWN ❑REMOVE CoQ OSE-TANI(&REMOVE ❑REPAIR PIPING �+ <br /> w <br /> HAS D ARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> o YES ❑ NO IF YES,DATE M M oJEAe <br /> ❑flEPLACE TANK ❑OTHER <br /> ja SOURCE OF DISCHARGE¢j ❑ TANK LEAK UNKNOWNRFILL ❑ RUPTURF/FAILURE ❑ SPILL <br /> y ❑ PIPING LEAK ❑ OTHER ❑ CORROSK)N ❑ UNKNOWN ❑ OTHER <br /> yw CHECK ONE ONLY <br /> O ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SU BMITTED ❑ POLLUTION CHARACTERIZATION <br /> My ❑ 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 /> 7.77 <br /> < ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> OO <br /> r <br /> w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(V5) <br /> ❑ VACUUM EXTRACTIVE) ❑ OTHER(OT) <br /> �lir>�ier si e crsserr .+v.T� <br /> ->,if 6e nac )esr y @ l++i�+ e k <br /> v-a rk.d 014Go.sou .,.�....E-�<i^ uS r��c�.A.e/ 4y 14- <br /> � /L�saplwv�y a7Groc� � <br /> vv /! vv Nsc ulaYq <br />