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COMrLETE THIS FORM IN EVENT <br /> UNOCCALS OF CONFIRMED LEAK OR SPILL <br /> AND SEND IN WITHIN 5 DAYS <br /> UNAUTHORME 0 RELEASE REPORT <br /> Permit # : Tank <br /> Facility Name : S i ze: <br /> Facility Address : Product : <br /> Date leak was discovered : <br /> Approximate date leak began : <br /> Describe fully the cause of the leak : <br /> How was the leak discovered? <br /> Has the leak been stopped? Date leak was stopped : <br /> How was the leak stopped? <br /> Resources affected : yes no threatened unknown of wells <br /> Air (vapor) <br /> Soil <br /> Groundwater <br /> Surface Water/Storm Drain <br /> Building or Utility Vault <br /> Other (specify) <br /> WatQr S <br /> Public Drinking Water <br /> Private Drinking Water <br /> Industrial <br /> Agricultural <br /> Other <br /> Submit this form Within 5 days of the discovery of a leak or suspected leak . <br /> Send t o : Local Agency with Quarterly Report. <br /> Page 12F <br />