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• • 9 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT <br /> EMERGENCYu,T//NO HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ VES REPORT BEEN FILED 7 ❑ VES E] NO 1 HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OFTHIS FORM. <br /> REPORT DATE CASE a <br /> && <br /> ee V/l 0 <br /> M M / W ✓ Y SIGN� ` / DATE <br /> NAMENAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> v ( )y6r-17yya <br /> w REPRESE NG ❑ OWNER/OPERATOR ❑ REGK)NAL BOARDCOMBpy�pR ,�r�+ COUNTY PUBLIC HEALTH SERVICES <br /> ¢ <br /> SERILOCIAL AGENCY ❑ OTHER �°11Y <br /> w ADDRESS P. O. BOX 2009 <br /> STREET CRY 445 N.SAN JOAOUIbAA%TREET ZIP <br /> J <br /> NAME <br /> ,�1 / ,,pp �s // CONTACT PERSON r <br /> /T�YVA1 aU7rcc� �'CO dor D� NxNow4r� C r r e U r c G (Z00 cfGG -G7J <br /> ADDRESS S-!Y E SGv f'f S A N-2 64 /s Zo/ � <br /> m g REST cm STATE ZIP <br /> FACILITY NAME APPLICABLE) ,v" / -r / 14 de <br /> OPERATOR PHONE <br /> z / v T7J ri, lG �1�3 ( Zc ) ��G P�7,z g 1 <br /> o <br /> a ADDRESS /, ` / <br /> w /5l'z (i y�s S cm GGTO couNry ZIPv <br /> CROSS STREET ¢ <br /> m &.0 /s vh W <br /> O LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> 2 m <br /> Z <br /> W_ <br /> W V <br /> ww REGIONAL BOARD PHONE <br /> �Q t <br /> w (�) NAME QUANTITY LOST(GALLONS) <br /> ❑ / <br /> NKNOWN <br /> Ow <br /> Q J <br /> 2 (2) <br /> h ❑ UNKNOWN <br /> i DATE DISCOVERED HOW DISCOVERED ❑ VENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> 2 61 6 MU o / o x r ❑ TANKT <br /> WT TANK REMOVAL ❑ OTHER <br /> Q DATE DISCHARGE BEGAN METH'96USED TO STOP DISCHA (CHECK ALL THAT APPLY) <br /> m <br /> > UNKNOWN REMOVE CONTENTS CLOS <br /> M D Y YE TANK B REMOVE ❑REPAIR PIPING <br /> ¢ <br /> HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> o ❑ YES NO IFYES,DATE REPLACE TANK E:] OTHER M ol dY Y <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ¢� ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> 0 O ❑ P17 LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> ww CHECK EONLY <br /> UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> i M+ ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> �y ❑ LEAK 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(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> IsffB�ENfO1CkTAM1) <br /> 6o ❑ CAPSITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY IRS) <br /> w <br /> w <br /> w< ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER <br /> J(OT) <br /> �yke. Sl �f.se SS/'+'�0/V Wo`� 6+r /12CZIt4.� �/ �C�4 N+ Jc�.i <br /> yL^{ GF �rU ✓( YL� La�4- <br /> DLe1D�C/� u�r� (� <br /> d nc <br /> HSC OS IS^1N <br />