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9) _ " i» <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ <br /> REPORT BEEN FILED?YES NO ❑ YES �NO i HEREBY CERi1FYTHATI HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> REPORTDATE DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM M I M D 7 '] DA$E s <br /> v, rior 1� � <br /> SIGNED <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE DATE <br /> w REPRESENTING ❑ OWNERIOPERA REGIONAL BOARD COMPANYOR AGENCY N�A{ME(� ]� <br /> S LGCAL AGENCY ❑ OTHER (S�, P � +V— C H D , <br /> ¢ ADD SS DO ^ <br /> a 7 <br /> srReeT em &TATE ZIP <br /> NAME 1 CONTACTPERSON PHONE <br /> m <br /> ❑ UNKNOWN ) <br /> m a ADDRESS <br /> 1 P 10, 4a� 7 'f 7 ckCITYb/� CA� ` 0 p ao7 <br /> 8AE <br /> Z <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE ) _ <br /> a <br /> ADDRES <br /> x <br /> w sTREEr cmc. <br /> y CROSS STREET <br /> o ' n h eocL <br /> i <br /> LOCAL AGENCY <br /> AGENCYNAME CONTACT PERSON PHONE <br /> `� <br /> w ' 1 S i <br /> i ( ) <br /> w REGIONAL BOARD PHONE <br /> na <br /> y (1I NAME QUANTITY LOST(GALLONS) <br /> a <br /> ❑ UNKNOWN <br /> (2) UNKNOWN <br /> ,Qec�fs <br /> i DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS 6 <br /> VAL <br /> OTHER <br /> a DTE DISCHARGE BE p Y ❑ TANK TEST TANK METHOD USED TO SODISCHARGE(CHECK ALL THAT APPLY) ) <br /> Ml DI y y UNKNOWN ❑REMOVE CONTENTS CLOSE TANK 6 REMOVE ❑REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED? ry ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> IS YES ❑ NO IF VES DATE u � X 0 5 ❑J I REPLACE TANK ❑ OTHER <br /> tD S RCE OF DISCHARGE ��_VVb CAUSE(S) <br /> j TANK LEAK ❑ UNKNOWN D�1 OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> x- <br /> 06 ❑ PIPING LEAK ❑ OTHER /-'E CORROSION ❑ UNKNOWN ❑ OTHER <br /> w n CHECKONEONLY <br /> O ❑ UNDETERMINED SOILONLY E] GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br /> jy LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> Q ❑ REMEDIATION PLAN ❑ yyC��A.SS��E CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FF) ❑ ENHANCED BIODEGRADATION(IT) <br /> MFEercK rw oETual <br /> w4 ❑ CAP SITE(CD)N EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> M'< ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT NEI ❑ OTHER(OT) <br /> w u, g, <br /> R <br /> HSC 05169% <br />