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C, u � <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) I CONTAMINATION SITE REPORT <br /> EMERGENCY / HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑VES �--,{ REPORT BEEN FILED? O YES �NO I HEREBY CERTIFY THAT I AMA DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> LJ �/ REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> REE/P``ORTOATE CASE* THE HEALTH-AND$AFTYCOOE. /... <br /> SIGNED — DATEr. <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> �iPIC- -7g6vFnl.4- o-,) 1163 <br /> REPRESENTING F-1WO ❑OWNEPERATOR REGIONAL BOARD COMPANY OR AGENCY NAME <br /> 0 �LOCKAOENCY ❑ OTHER .SrA/f`�0l.�t7l Al GO /�(J�l-IG fFFi G'*fI SF V <br /> w <br /> � ADDRESS <br /> z/j-/5 <br /> MEET CRY &TATE 2w <br /> w� NAME CONTACTPERSON PHONE <br /> �g5€ 5�K'TLY-1 l0/4T7lV 6T ❑ UNKNOWN <br /> 6 a <br /> ADDRESS ,(,,J1l11 <br /> E32 S• E� Dom T`�a -�'7—[SW DRY STATE v <br /> FACILITY NAME IF APPLICABLE) OPERATOR PHONE <br /> 6 S?L'GL!7b `AT/N 6- A erlRle� TNL (za ) 9L1SS-00 1 <br /> < ADDRESS <br /> 63z 5, EG DoDd S KTbl�l s9✓J �oAavlN c��j2o <br /> STREET CRY CDONIY DP <br /> M <br /> CROSS <br /> STREET <br /> x� 1 , <br /> O LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> 3a 5.4N Tv.AOu(iI Co. SF,Q✓icE fR/L Evf )416 -3/3c44 <br /> REGIONAL BOARD PHONE <br /> NAME QUANTITY LOST(GALLONS) <br /> 2rUNKNOWN <br /> (2) <br /> N <br /> ❑ UNKNOWN <br /> i DAATEDISCOVERED `1 HOWDISCOVERED ❑ NTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCECONDITIONS <br /> U MI MI 3 D I D45( Y Y O TANKTEST TA REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN Imo,/ METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M M D D v r 1� N E)KNOWNREMOVECONTENTS ❑ REPLACE TANK Er <br /> CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED? ❑ REPAIRTANK ❑ REPAIRPIPNG ❑ CHANGE PROCEDURE <br /> o ❑ YES ❑ NO FYES.DATE MI M D D YJ Y ❑ OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ❑ TANKLEAK /❑-UNKNOWN 0 OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> F-] PIPINGLEAK F-1OTHER ❑ CORROSION E�J I�NKNOWN ❑ OTHER <br /> ww CHECK ONE ONLY <br /> F-] UNDETERMINED E:] SOIL ONLY ❑ GROUNDWATER ❑ DRINKINGWATER- (CHECK ONLY F WATER WELLS HAVE ACTUALLYBEEN AFFECTED) <br /> CHECKN Y <br /> w NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> jy ❑ LEAK 3EING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ <br /> REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK PPRORRIIAT A TIONS) ❑ EXCAVATE&DISPOSE(ED) E--] FP) E::]REMOVE FREE PRODUCT( ENHANCED BIO DEGRADATION(IT) <br /> oQ ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(" ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY IRS) <br /> a� ❑ CONTAINMENT 13ARRIER(CB) ❑ NO ACTON REQUIRED(NA) ❑ TREATMENT ATLgOINP(HU) ❑ VENTSOIL(VS) <br /> ❑ VACUUM EXTRACT C4Q E2`OTHER(OT) AL'a.(� <br /> l <br /> Sola R o�rS Fie��( T.6�NL R64I aNait,A'rE 50it- conrrA.(YlrlAtWW. 00 <br /> s�TE A���iH�/��vILL 6� /PF-4�litiPEED � pulE Tff� rld-�-v�E <br /> �Nr� X iEN T aFcoN r/2s,tN iDT/fl- ,e �Qt✓/�O B 7� ?�� A�R40A��T� <br /> APF-G/iud�idY .AGFJL/GY <br /> 119C05(1110% <br />