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�/ �c 1 Y6�- <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)!CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES 'FOR LOCAL`AGENCY USE ONLY: <br /> REPORT BEEN FILED? I HEREBY CERRFYTHAT I.HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> ❑ YESS� NO /y] [DYES NO DISIRIyB IIX4 ON THEW UOTQN(S/HE`�EUII\ON THE BACK PAGE OF THIS FORM. <br /> REPORT DA 1 5 CASE <br /> `9 �,� z WVI '/� � � <br /> 'SGMED Z— DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SI ATTIRE <br /> m U� � •T�k��- � �����( � CST,,,-��-F <br /> MQj REPRESENTING ❑ OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY <br /> /OR AGENCY NAME <br /> S OCAL AGENCY ❑ OTHER S cl 1 ��J �• lJ <br /> 364 E 1k/e b-er' -Ave,-TK cd Rbc-x- Cft <br /> STREET CRY STATE 2iv <br /> j w U/�.�V��y�Y�l I�/+ 1�y/-`� ❑ <br /> PHONE <br /> NAMECONTACT PERSON <br /> UNKNOWNwl `-Rea ©( Vel 6M) -33b <br /> H g ADDRESS <br /> STATE ap <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> � S <br /> <w ADDRESS �. �r7J-3 n) <br /> S22C(Z <br /> =INW <br /> ZIP <br /> CROSS STREFj <br /> �kL c. <br /> Q LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> G Ptts 1 ett� iA T r(r �fe �u�) 3Yc/l <br /> w REGIONAL BOARD PHONE <br /> GV Cwtt ra Ua�le� ►�e � er- c9rl� X55- a <br /> H fl) NAME QUANTITY LOST(GALLONS) <br /> wO <br /> J (nQ UNKNOWN <br /> m m <br /> N ❑ <br /> UNKNOWN <br /> i DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> 2 I o r ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Cv UNKNOWN ❑REMOVE CONTENTSOSE TANK6 REMOVE ❑REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK d FILL IN PLACE ❑CHANGE PROCE R <br /> VES ❑ NO IF VES,DATE MI MI r v ❑REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> j ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> m O ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> mi 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 /> Z ❑ NO ACTION TAKEN 1)Q-'�PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHMACTERIZAT10N <br /> jy ❑ IEAKBEINGCONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> D ❑ 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(I7) <br /> amara rw oevwl <br /> w4 ❑ CAP SITE(CD) ❑ EXCAVATE 8 TREAT(ET) ❑ PUMP 6 TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> ~ <br /> Qa ❑ CONTAINMENT BARRIER(CB) F-1NO ACTION REWIRED(NA) ❑ TREATMENT AT HOOKUP(Hu) ❑ VENTSOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑�� pOTHHER(OT) <br /> Siff Od� 1440T►JL I OCR- <br /> 4 �e�®nn,eu� ,-►D c@c-�-�,rry��n-e r�-�.re, cwt '��c(�c�-'F of'c�6cl�w.��.. <br /> s <br /> NEC 61AiA <br />