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9a— (4,pe) <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERG YSERVICES <br />REPORT BEEN FILED? <br />FOR LOCAL AGENCY USE ONLY <br />1 HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br />F-1 VES VES ❑ NO <br />DISTRIBUTION SHOWN ON THE INSTRUCTK)N SHEET ON THE BACK PAGE OF THIS FORM <br />4" <br />�Z ., - G <br />REPORT DATE <br />CASE <br />?'.I o <br />SIGNED DATE <br />NAME OF INDIVIDUAL FILING REPORT <br />PHONE <br />SIGNATURE <br />m <br />r o O Z_ <br />(10 ) Yb vf vyo <br />w <br />REP RE TING ❑ OWNERIOPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME <br />QQ // <br />fj <br />1a <br />LOCAL AGENCY [:3 OTHER <br />ADDRESS ` C Q <br />ll q( -N. San✓� C/;. .�, �(�6''oa-71 �(%yl V/ <br />STAE ZIP <br />w <br />NAME �'n f./� �/.'. S j <br />CONTACT PERSON <br />PHONE <br />i ¢ <br />n �H rQ El UNKNOWN <br />/'' <br />JeP✓[ (, 0. C G- <br />q� <br />1 3'-! <1/ <br />aa <br />ADDRESS <br />a 5 A Y: ivAy ,�lY c5'u c fr 2040 Eti n fir n c <sC.> <br />.5-77GtJ <br />3 CITY STATE ZIP <br />FACILITY NAME (IF APPLICABLE) <br />OPERATOR PHONE <br />1/tn &�a, <br />/� yc.�k ( Zoe q& �/Sl <br />0 <br />re v<` <br />s k ss/t <br />g< <br />ADDRESS �/ v�x <br />oo S �uroo c� <br />ly <br />SfREEf GfY cduLO <br />ZIP <br />y <br />CROSS STREET <br />lot- CIL (4, 1 <br />p <br />LOCALAGENCY AGENCY NAME <br />CONTACT PERSON <br />PHONE <br />z - <br />( 1 <br />W U <br />w <br />REGIONAL BOARD <br />PHONE <br />_E <br />( 1 <br />y <br />(7) NAME QUANTITY LOST (GALLONS) <br />Z, <br />a <br />0 µ� ❑ UNKNOWN <br />V <br />y z <br />` I 1°.4 ♦ d'" II..CA .GUNKNOWN <br />i <br />DATE DISCO ERED <br />HOW DISCOVERED ENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br />W <br />e <br />D Y <br />❑ TANK TEST TANK REMOVAL ❑ OTHER <br />�u <br />m <br />ATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARG97CHECK ALL THAT APPLY) <br />aUNKNOWN <br />❑ REMOVE CONTENTS CLOSE TANK&REMOVE ❑REPAIR PIPING <br />w <br />p <br />M D Y Y <br />❑ REPAIR TANK ❑ CLOSE TANK & FILL IN PLACE ❑ CHANGE FIR RE <br />HAS DIS BEEN STOPPED T <br />fS2 <br />E24YES ❑ NO IF YES, DATE <br />❑ REPLACE TANK ❑ OTHER <br />N D Y Y <br />SOURCE OF DISCHARGE <br />CAUS(S) <br />'m <br />E3 TANK LEAK UNKNOWN <br />❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br />8 <br />r7PIPING EAK ❑ OTHER <br />❑ CORROSION ❑ UNKNOWN ❑ OTHER ' <br />w w <br />CHECK ONLY <br />UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER . (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECKONEONLY <br />w� <br />❑ NOACTIONTAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br />W;5 <br />❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SI7E ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br />O y <br />❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br />CHECK APPROPRIATE ACTIONS) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) E] ENHANCED BIODEGRADATION (IT) <br />w4 <br />IS3eWAIDAOFiu81 <br />❑ CAP SITE (CO) ❑ EXCAVATE & TREAT (ET) ❑ PUMP d TREAT GROUNDWATER (GT)❑ REPLACE SUPPLY (RS) <br />W< <br />❑ CONTAINMENT BARRIER (CB) ❑ NO ACTION REQUIRED INA) ❑ TREATMENT AT HOOKUP (HU) ❑ VENT SOIL (VS) <br />❑ VACUUM EXTRACT(VE) ❑ OTHER (OT) <br />r <br />S vi / 5 a'ele <br />`vti <br />w <br />A.a l� �ie n� c e A, Cl�'�e+ na r...o n Q 4,Lwu + ex-Je n7F C)'7 con's •n i rr.. ' < <br />gas <br />;Sr 7 <br />ropo;mad br //�«D <br />NSC Ds lS'YN <br />