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, 1 lo <br /> UNDERGROUND STORAGE UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES_ FOR LOCAL'AGENCY USE ONLY <br /> ❑ YES NO REPORT BEEN FILED? <br /> ❑ YES ❑ NO :THEREBY CERRFYTHATI HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> REPORT DATECASE i DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE RACK PAGE OF THIS FORM <br /> Q <br /> D SM i_,3 , :9, <br /> V SGNED DATE <br /> NAME OF INDIVIDUALFIUNG REPORT \ PHONE SIGNATURE � �y � <br /> I�f�` ti'a. O r r S P10V b,?3 4b PiGliU e✓ ,��t` <br /> w REPRESENTING ❑ OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> S LOCAL AGENCY ❑ OTHER V V(,L P'"� �D <br /> ADDRESS VVVV "`���� <br /> 3 o t, t� e,4� f} r�e, 3'' �uo�`� ool(�� C14 <br /> (`Y STATE nn <br /> i N� V ❑UNKNOWN TACT PERSON PHONE <br /> lie Q� Baa ) -q I <br /> H n ADDRESS <br /> P, o, 6o X 577 0 (o mo oCe s+o C,4 q�3�r <br /> cm &TAre <br /> Z FACILRY NAME(IF APPLICABLE) OPERATOR PHONE <br /> UADDRESS <br /> —y CROSS STREET <br /> z LOCALAGENCY AGENCY NAME CONTACT PERSON <br /> m PHONE <br /> Z w s 3-. C�. P H 5 — t I Icc. 3 r S (a o ) <br /> Z 8V <br /> F. REGIONAL BOARD PHONE <br /> a< Lo ( ) <br /> w (i) NAME OUANTRY LOST(GALLONS) <br /> OyD <br /> ❑ UNKNOWN <br /> �O <br /> m> m <br /> N <br /> ❑ UNKNOWN <br /> i DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> o ✓M 1 3D w �v ❑ TANK TEST F-1TANKREMOVAL ❑ OTHER <br /> Q DATE DISCHARGE BEGAN METH OD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> u .1 yl yl UNKNOWN REMOVE CONTENTS CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK ❑CLOSE TANK&FILL IN PUCE ❑CHANGE PROCEDURE <br /> La YES ❑ NO IFYES,DATE O ' D /Y ❑REPLACE TANK ❑OTHER <br /> §OURCE OF DISCHARGE CAUSE(S) <br /> aj ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> a <br /> m O ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> Hn CHECK ONE ONLY <br /> O ❑ UNDETERMINED X <br /> SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> QZ ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> mLEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(3) EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> on p ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w- <br /> w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED MA) ❑ TREATMENT AT HOOKUP(Hu) <br /> ❑ VENT SOIL(VS) <br /> ¢ ❑ VACUUM EXTRACT(VE) OTHER(OT) S I -�-p Q,S, p S S nww,L.6 <br /> r-0 4-L429 <br /> 7-eye <br /> to C HD Z464Zt- <br /> s��l�% <br />