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-- low c7q —u/ IV <br /> 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 REPORTBEEN FILED 9 [--] YES ❑ NO I HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORTDATE 9 CASES <br /> ON 3u • �r SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> 'w Q61IHb83y1 <br /> w REPRESENTING D OWNEFVOP T R ❑ REGIONAL BOARD COMPANY OR AGENCY NAP _ )\ <br /> ¢ LOCAL AGENCY ❑ OTHER S {S_ Co l 3 <br /> 8 <br /> ¢ AD E s oa x `� "'' SfoGAxo� C.9 `15x07— o Fr$' <br /> STREET CT' STATE IIP <br /> J NAME /� /1,® CONTACTPERSON <br /> i 2 C&Va 1 e,fe- UNKNOWN <br /> Oa a ADDRESS 9 (\f `(\� ®��/ �/y� /J� <br /> ¢6 I V `'� STRW/✓V_ni[.,wL{/Vi V�/\!�� 5✓QD(o <br /> STATE P <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ^�f <br /> O <br /> Q ADDRESS <br /> o , <br /> F srRE cm zIP <br /> —y CROSS STREET <br /> O LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> _� PNS—D PHONE <br /> w w REGIONAL BOAR <br /> Q w <br /> a ` C <br /> y D) NAME QUANTITY LOST(GALLONS) <br /> w Q <br /> U <br /> a� ❑ UNKNOWN <br /> m (2) <br /> m ❑ UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> OI 3M�f`D a D �v �r ❑ TANK TEST TANK REMOVAL OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY <br /> w u D D Y y UNKNOWN ❑REMOVE CONTENTS CLOSE TANK&REMOVE E:]REPAIR PIPING <br /> 0 HAS DISCHARGE BEEN STOPPED 9 ❑REPAIR TANK O CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> o VES ❑ NO IF YES,DATE 3 uI 6o / 0 9v / r F-1REPLACETANK Q OTHER <br /> LD SOURCE OF DISCHARGE `CAUSES) <br /> ¢j TANK LEAK ❑ UNKNOWN OVERFILL O RUPTURE/FAILURE ❑ SPILL <br /> NO PIPING LEAK ❑ OTHER ❑_CORROSION ❑ UNKNOWN ❑ OTHER <br /> yw� CHECKONEONLY <br /> O UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CH�ECK/ONE ONLY <br /> z IXI NO ACTION TAKEN O PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> ¢Q JJ�❑--�� LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS <br /> ¢F <br /> O w ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTIONS) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) \ <br /> IaiE e�cx Rn oe*us1 <br /> w ❑ CAP SITE(CD) ❑ EXCAVATE 8 TREAT(E1) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED( ) ❑ TREATMENT AT HOOKUP(HU) O VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) OTHER(OT) /J Q,SSe-&S 6`7 <br /> w �'oc lS / fir �_�v� 07 <br /> Qui`dna CSG �ST 's / �/�' e-z <br /> — RSC OS IAS'+1 <br />