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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br /> EMERGENCY / HAS STATE OFFICE OF EMERGENCY SERVICE FOR LOCAL AGENCY USE ONLY <br /> �M REPORTBEENFLED? I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> ❑YES I o N ❑YES NUJNO ;REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> REPORTDATE CASES THEN AND SAFTY CO _ <br /> N N Y <br /> SIGNED DATE <br /> W <br /> NAME OF/INDIVIDLF0.ING REPORT PHONE SIGNATU <br /> 6 (�9) �3�ffo RJZa <br /> q REPRESENTING E] OWNEWOPERATOR ❑ REGIONALBOARD ANY OR AGENCY NAME <br /> rt LOCAL AGENCY ❑ OTHER <br /> ADDRESS �1.Sa'OS <br /> ME HNQD/ND q l/K1��}L()FD ❑ CONTACTPERSON PHONE <br /> f� /UNKNOWN � <br /> a ADDRESS q5� <br /> SrDcA) 3 <br /> CRY SPATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> (20 &-909 <br /> � n <br /> < ADDRESS <br /> CITY NTY <br /> mCROSSSTREET STET TYPE OF AREA ❑COMMERCIAL❑INDUSTRIAL❑RURAL TYPE OF BUSINESS O RETAIL FUEL STATION <br /> k1Pj7Q,e/s0ti1 EV RESIDENTIAL ❑OTHER ❑ FARM ©OTHER <br /> g LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> „ r o nom ;) �8= <br /> REGIONAL BOARD PHONE <br /> C GcJQC'Bs l ) <br /> O) NAME QUANTITY LOST(GALLONS) <br /> / e 2 uMNOWN <br /> (2) <br /> w ❑ UNKNOWN <br /> DATEDISCOVERED HOW DIS(bVERED O INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ N)ISANCECONDRIONS <br /> M M S--.i ffr v ❑ TANK TEST �NK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN � METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M M o o Y Y &?'-UNKNOWN MOVE CONTENTS ❑ REPLACETANK ❑ CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED? Ej REPAIRTIWK ❑yam REPAAIIIRPIPWG ❑ CHANGE PROCEDURE <br /> o ❑ YES ❑ NO IFYES,DATE M .1 I, DI yi Ei OTHER rwnt a <br /> SOURCE OF DISCHARGE TANKS ONLYCCAPACITY MATERIAL CAUSE(S) <br /> ❑ TANKLEAK �NKNOWN GAL, ❑ FIBERGLASS O OVERFILL ❑ RUPTURErFALURE <br /> ❑ PIPINGLEAK AGE YRS STEEL ❑ CORROSION ©--IN(NOWN <br /> ❑ OTHER EE�ONKNOWN ❑ OTHER O SPILL ❑ OTHER <br /> w� CHECKONEONLY <br /> 3�: ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKINGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECKONEONLY <br /> ¢< F-1SITE INVESTIGATION IN PROGRESS(DEFINING EXTENTOF PROBLEM) F-] CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> ❑ NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVALABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> b ❑ CAP SITE(CD) ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> ' ❑ CONTAINMENT 13ARRIER IDS) ❑ EXCAVATE&TREAT(ET) ❑ PUMPB TREAT GROUNDWATER(DID ❑ REPLACE SUPPLY IRS) <br /> ❑ TREATMENT AT HOOKUP(H)) ❑ NO ACTION REOUIRED(NA) ❑ OTHER(OT) _ <br /> Tiir-/-Av✓ srtc GSS�Ss»�n7 ma /re KJ7/ P <br /> ra w Oct, <br /> HSG W(d97) <br />