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wC3 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVIC <br /> 'FOR LOCAL AGENCY USE ONLY. <br /> ❑YES NO REPORT BEEN FILED '1 HEREBY CERTIFY THAT I AM A.DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> ❑YES REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 251807 OF <br /> R/9E�/PORT DATE•//J 7 CASES THE EALTH ANO SAETY CODE, <br /> VM M l� �D ' ..�9 % 1 J/ _1 <br /> Y Rf_� /6ATE/l <br /> NAME OF INDIVIDUAL FILING REPORT PHONE <br /> SIGNA.URE <br /> L <br /> REPRESENTING <br /> � ❑ OWNE(YOPERATOR ❑ REGIONAL ROARD COMPANY OR AGENCY NAME <br /> a L.1? SAL AGENCY ❑ OTHEq <br /> w <br /> m <br /> ADDRESS <br /> qq5 <br /> A.7, oc fanr <br /> w pTO' C�- ���2 <br /> NAME <br /> 9 ATE SIP <br /> m _ !,,c CONTAACT/PERRSSON PHONE <br /> i V. Y' UN ❑ UNKNOWN w L,1� ✓ (2r�R) 913-,S�IoZ <br /> S a <br /> ADDRESS e <br /> 2�I�fl Nrgri DRIVE �k�on Cfr Q52-03FACILITY NAME(IF APPLICABLE) cm WA p <br /> OPERATOR PHONE <br /> ADDRESS <br /> piX93 <br /> 9�l NR W Dr)�v Stock fan S�Jea9�;, �i'S'??ti3 <br /> �+ CROSS STREET cmc, <br /> REU <br /> 60ash r <br /> LOCALAGENCY <br /> F AGENCY NAME CONTACT PERSON PHONE <br /> wO / <br /> mg <br /> REGIONAL ARID <br /> _a PHONE <br /> m (1)/7 NAME <br /> QUANTITY LOST(GALLONS) <br /> F <br /> r� (2) �UNKNOWN <br /> DATE DISCOVEREDE] UNKNOWN <br /> w �/ HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> OM M o G...p (r / v ❑ TANK TEST ©ITANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN I--�,/ METHOD USED TO STOP DISCHARGE(CHECK ALL THATAPPLY) <br /> $N ,—M ,/M D o v y Ekl5KNOWN dREMOVE CONTENTS ❑ REPLACETANK ❑ CLOSETANK <br /> HAS u �✓ YES DISCHARGE <br /> ❑BEEN <br /> NO STOPPED <br /> DATE Q M �M /o O o v v ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> ❑ OTHER <br /> tiw SOURCE OF DISCHARGE CAUSE(S) <br /> ❑ TANK LEAK [Rl K VM ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> ❑ PIPINGLEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> ww CHECKONEONLY <br /> ❑ UNDETERMINED ❑ SOIL ONLY I��-/GROUNDWATER <br /> LJ ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> ¢� ❑ NO ACTION TARN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> �y ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> ❑ REMEDIATIONPLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUPUNDERWAY <br /> CHECK APPROPRIATE ACTION(S) \ <br /> 0z I�erxrexuErwuq ❑ EXCAVATE B DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> w4 ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER❑ (GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ CONTAINMENT BARRIER(CS) ❑ NOACTIONREQUIRED(NA) L] VENTSOIL TREATMENTAT HOOKUP(HU) S <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) ❑ ry ) G <br /> ltrfhe✓ 5rft, �ISstsS/Y�iTI Wil/ l,� regi/r�cF terr»rne ffie ra <br /> �yc'Eer-/tf CfirfGtl�Aon }aY� , aS (� EGL¢ 2��pa�rig7� <br /> re91)ta'&ry qy--n <br /> I wtl Very <br />