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x <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCYHAS STATE OFFICE OF EMERGENCY SERVICfcS FOR LOCAL AGENCY USE ONLY <br /> [:] YES NO REPORTBEENFLED? [DYES NO I HEREBY CERTIFY.THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> REPORT DATE OASEt THEHEAL ANDSAFTY00 <br /> Z2� <br /> M I M 1 0 Y V SIGNED DA E <br /> NAME OF INDIVIDUAL FILING REPORT PHONE yJL1 ,5 i SIGNATURE <br /> e4 A <br /> REPRESENTING OWNEWOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME /� <br /> R ❑ LOCALAGENCY F—] OTHERS /\L� A <br /> w¢ ADORES <br /> �3 90 Vit//o Q) Puss Rol•-STE 0/too Concord C A- o!ys-cb <br /> CITY WATE v <br /> NAME J CONTACTPERSON PHONE <br /> m '� / / D,` O , ❑ UNKNOWN ;u C LNA� H,St ( )��q '/a) <br /> ADD1E� Ids Abo�� or <br /> A o• dox NDa? C.4WAn <br /> 9xsay <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> 5 if .sfa))f•`vr�(� l r 1U lel ✓/ nc�nCk {(.�D�1) qS�-(o15e�f1 <br /> ADDRESS 301 A/Cl'1.1AL rola X1017 /�C��d Y\ -(),qA 1;1 9�ov/9 <br /> mJ e cm cou ZIP <br /> CROSSSTREET TYPEOFAREA COMMERCIAL❑INDUSTRIAL ❑RURAL TYPE OF BUSINESS RETAIL FUEL STATION <br /> ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> Ct A Jo- <br /> k;r� Co, ENL/,`,ro,MeofaakAs e t v <br /> REGIONAL BOARD /PHONE <br /> ra u l 'e c <br /> m 11) NAME QUANTITY LOST(GALLIXJ <br /> UNKNOWN <br /> m <br /> w ❑ UNKNOWN <br /> �- DATEDI,SSCC/OVERED p HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSUflFACE MONITOR ❑ NUISANCE CONDMIONS <br /> Ou lu 0D D /Y 0Y ❑ TAW(TEST ❑ TANK REMOVAL OTHER /7/� (A <br /> DATE DISCHARGE BEGANMETHOD <br /> MQ OHEMOV CONTENTSTOP S*ARGE(CHECK ALL THAT❑ REPLACE TANK ❑ CLOSE TANK <br /> iy M M D D V Y 11 " <br /> HAS DISCHARGE BEEN STOPPED? ❑ REPAIRTANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> o ❑ YES ❑ NO FVES,DATE M M D D v Y ❑ OTHER <br /> y SOURCE OF DISCHARGE TANKS LY ACITYyA�A MATERIAL OA1SE(S) <br /> ❑ TANK LEAK UNKNOWN / �UM a-O�'OAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURETALURE <br /> 0 F-1PIPINGLEAK AGEYRS STEEL E:] CORROSION �NKNOVM <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w w CHECK ONE ONLY <br /> ❑ UNDETERMINED All"SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> r CHECKONEONLY <br /> ss ❑ RE NVESTIOATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY)¢r <br /> U% NO ACTKXJ TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TOPROCEED ❑ EVALUATING CLEANUP ALTERNATIVES �V- <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) I <br /> Z� ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT Y.lGROUNDWATER(O��'//t) ❑ REPLACE SUPPLY IRS) f�VVV�J� <br /> F-1TREATMENTAT HOOKUP(HU) E::] NO ACTION REQUIRED INA) EKOTHIER(OT) <o e�/1f/^NA Afcl V l <br /> rf sit¢ Qssessm� be h.2 GGveea( � <br /> ��eX� Gv hau-Lll�aG S <br /> IacaaµeA /, <br />