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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 /> El YES NO [:] VES <br /> REPORT BEEN FILED? I HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> NO <br /> DISTRIBUTION SHOWNA THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT DATE CASE# 2� V <br /> u b M U Y N G DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> fzwe m[N v ati rjkm. (20 ) 16,6 bifo <br /> w REPRESENTING ❑ OWNERIOPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY N E <br /> SLOCAL AGENCY ❑ OTHER SSG E <br /> ADDRESS c] /'-oL V, C4 -/lzo z- <br /> 6VV ✓ • gNiFE! , Cm STATE ZIP <br /> W NA��R{lfnl � `94k ��,.�,�. s.� CONTACT P(ER�SO1N L� (HO�e 1 _ q <br /> 7 G V"Lj UNKKNNVOWN iA (,V �VO I <br /> Oa <br /> y n ADDRESS <br /> 3bg-7 b�bwfnTn� GI , S'nrJ �o� CR C13'/Z2 <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> A-L kA 1r L10 <br /> W <br /> ADDRESS <br /> �� $, F L borowa S�• sfo&(Lk, S� 3,04avo gT203 <br /> STREET CITY COUNTY v <br /> y CROSS STREET <br /> 5t 6%V f . <br /> O LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> �N <br /> ~ ( / <br /> W <br /> w� REGIONAL BOARD PHONE <br /> z ( <br /> w (i) NAME T �p QUANTITY LOST(GALLONS) <br /> l D T L � I I \ IJ I A/�/G gew <br /> 1 ZP�Ki I O I ,` UNKNOWN <br /> akQ�O�C� "A D Y.Tz j -(pa UNKNOWN <br /> i DATE DISCOVERED �J HOW DISCOVERED ❑ INVENTORY CONTROL SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> oml 'Z (i o Y ❑ TANK TEST ❑ TANK REMOVAL OTHER �} (/th <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP w DISCHARGE(CHECK ALL THAT APPLY) <br /> u D Y UNKNOWN [:] 17�IAAREMOVE CONTENTS CLOSE TANK REMOVE ❑REPAIR PIPING <br /> T <br /> HAS DISCHARGE BEEN STOPPED 4 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> O YES ❑ NO IF YES,DATE u O Y Y ❑REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> j TANK LEAK ❑ UNKNOWN ❑ OVERFILL RUPTUREIFAILURE ❑ SPILL <br /> a <br /> w0 PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> w w CHECK ONE ONLY <br /> ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> Z ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ <br /> REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> IS3BYA(IOIOEfAUI <br /> 4 ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY IRS) <br /> w F. <br /> Mw a ❑ CONTAINMENT BARRIER(CS) ❑ NO ACTION REQUIRED NA) ❑ TREATMENT AT HOOKUP(HU ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) 5d OTHER(OT) Q ra4 <br /> f2 <br /> z <br /> w <br /> f <br /> z <br /> NSC CS IAs% <br />