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UNDERGROUND STORAGE TANK 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? O YES Q NO HEREBY CERTIFY THAT I AM fK .REPORTED THS NFORMATIONATO DESIGNATED <br /> LOCAL OFFICALSNMENT PURSUANT EMPLOYEE <br /> O SECTION 251807AVE- OF <br /> REPORTDATE CASE# THE HEALTH AND SAFTY CODE / I <br /> 0,I -I SDI YJ Y SIDNED DATE <br /> — <br /> NAME OF INDIVIDUAL FLING REPORT PHONE SIGNATURE <br /> 16 a�td C-.,A -- V oq) 4ca-3ucfv <br /> 0 REPRESENTING O OWNEWOPERATOR O REGIONALBOARD COMPANY OR AGENCY NAME <br /> SLOCAL AGENCY O OTHER 5p,.� �a., v:�. LOgp. I C'r Gti�T� D�3�✓�C� <br /> ADDRESS <br /> CRY STATE ZP <br /> NAME {� 1 CO1NTACT{P�ERSON lPHONE <br /> L \Co �TNgT✓Q- UNKNOWN L�• K•7 1�'1T1n6�✓t (Zo9) ^i N(- qZ� <br /> i ADDRESS t� <br /> a (23 3cREffGTE ap 4SLoy <br /> FACLITYNAME(IFAPPLICABLE) OPERATOR <br /> n PHONE <br /> LC K. t Lt Ro lhi...a'4✓� (Z� 9yi'zg2� <br /> ADDRESS liSay+ T �ih <br /> y CROSSSTREET TYPE OF AREA I})—]I'COMMERCIAL E]INDUSTRIAL Q RURAL TVPEOFBUSINESS O RETAIL FUEL STATION <br /> O flESIDENTIAL O OTHER O FARM O OTHER <br /> LOCALAGENCV AGENCY NAME CONTACT PERSON PHONE <br /> m / <br /> �w So.1S ITh Lor_a.l ecli� Q�s�,r.� La,,,%�t �•�,.Ilo. ('2-mac) 46F -3Y�h <br /> REGIONAL BOARD `` <br /> a 11.\It PHONE <br /> 2 <br /> yqq (11 NAME QUANTITY LOST(GALLONS) <br /> UNKNOWN <br /> (2) <br /> O UNKNOWN <br /> W DATE DISCOVERED (� HOW DISCOVERED O INVENTORY CONTROL O SUBSURFACE MONITORINGO NUISANCECONDITIONS <br /> M 9 M 2-.1 .1 &v 6 v TANK TEST .TANK REMOVAL E:] OTHER <br /> 5 DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M M D D v y UNKNOWN Q REMOVECONTENTS O REPLACETANK CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED 7 REPAIR TANK E:j REPAIR PANG CHANGEPROCEDURE <br /> p VES O NO IFYES,DATE QCk L O <br /> M MI O DI yfo Y OTHER O <br /> u� SOURCE OF DISCHARGE TANKS ONLY ACITY MATERIAL CAUSE(S) <br /> O TANK LEAK UNKNOWN �!" a'•� GAL, O FIBERGLASS O O <br /> "`YYY---"' OVERFILL RUPNRFFAILURE <br /> O PIPINGLEAK AGE YRS O STEEL O CORROSION UNKNOWN <br /> 0 OTHER UNKNOWN Q OTHEREj SPILL O OTHER <br /> w w CHECK ONE ONLY <br /> a <br /> U� Q UNDETERMINED SOILONLY O GROUNDWATER O DRINKINGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY <br /> zm <br /> ¢< O SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) 0 CLEANUP IN PROGRESS [::] SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> V% O NOACTIONTAKEN O POST CLEANUP MONITORING IN PROGRESS Q NO FUNDS AVAILABLE TO PROCEED Q EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> aO CAP SITE(CD) O EXCAVATEg DISPOSE(ED) O REMOVE FREE PRODUCT(FP) ENHANCED BIODEGRADATION(IT) <br /> O CONTAINMENT BARRIER(08) O EXCAVATE g TREAT(u) O PUMP&TREAT GROUNDWATER(GT) O REPLACE SUPPLY IRS) <br /> O TREATMENT AT HOOKUP(HU) 1' O NOACTONREOUIRED(NA) O OTHER(OT) <br /> ✓V� \ swnnnKA�gM �1� (, �✓v1�f. \�`+��/`(.Nn OJ41 <br /> P� Cp <br /> HSM( ,) <br />