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s-v LIU <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED 7 O NO 1 HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> AYES NO YES DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORTDATE CASE i <br /> IM Y SK;NF1) DATE <br /> NAME OF INDIVDUAL FILING REPORT PHONE SIGNATVRE <br /> Lef; 8r -s ( ) `tbg-3%e <br /> O OWNER/OPERATOR Q REGIONAL BOARD COMPANY OR AGENCY NAME <br /> w REPRESENTING E 4� 1�, <br /> SLOCALAGENCY0L QOT,HHER1 /� p/��.(� ��j/// 4 n\ �,�y �r�J J / J (�A^{ <br /> ADDRESS <br /> T L wz be- / / . o, �. _/� �l��V v1a�I#,'u c1�1 9$�D I <br /> m�ET cm• STATE ZIP <br /> i NAME/n' p A CONTACTPERSONN PHONE <br /> m �/ C r u' s I + UNKNOWN (5io) 8'fa-qc>!s <br /> N VV <br /> 00.< ADDRESS <br /> D �, -500 4 �/• ///{/�µA <br /> n SCITY TFEET STATE IP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> TR iq C /LG h er/��v ro-v� but l c, C hara,n ' � t &31P-tea <br /> a ADDRESS Q 17 C iJ L • 7I\/Z l� J U. { 53 (p <br /> U ,\ <br /> 1 7 �Er cm couxrr zIP <br /> w <br /> y CROSS STREET <br /> =—�05 <br /> O LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> Z03 yl 63 <br /> w w REGIONAL BOAR PHONE <br /> ` R L3 ( ) <br /> H (9 <br /> NAME QUANTITY LOST(GALLONS) <br /> O /IIDtDI I�tG I� - � ""��.Y UNKNOWN <br /> U �� <br /> W <br /> Q� <br /> y a UNKNOWN <br /> i DATE DISCOVERED 9 HOW DISCOVERED INVENTORY CONTROL O SUBSURFACE MONITORING O NUISANCE CONDITIONS <br /> Mlu 47. /Y Sr O TANK TEST TANK REMOVAL OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DIISSCCHAARRGE(CHECK ALL THAT APPLY) <br /> i UNKNOWN REMOVE CONTENTS IXICLOSE TANK6 REMOVE E::]REPAIR PIPING <br /> ml Ml DI Yl L�o HAS DISCHARGE BEEN STOPPED 1 Y 0 REPAIR TANK O CLOSE TANK&FILL IN PLACE 0 CHARGE PROCEDURE <br /> OYES 0 NO IF YES.DATE /u / Op / Y �Y OREPLACE TANK XOTHER 'E' <br /> OURCE OF DISCHARGE CAUSE(S) <br /> � TANK LEAK , UNKNOWN E�jOVERFILL RUPTURE/FAILURE SPILL <br /> rOnO I PIPING LEAK 0 OTHER CORROSION UNKNOWN O OTHER <br /> ww CHECK ONE ONLY <br /> O UNDETERMINED SOIL ONLY GROUNDWATER DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> W O NO ACTION TAKEN PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br /> �y O LEAK BEING CONFIRMED 0 PRELIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS <br /> O O REMEDIATION PLAN O CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUPUNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE&DISPOSE(ED) O REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(m y <br /> 4 Z ISi B.YAt Kn ckT/A81 �>J \ <br /> CAPSITE(CD) Q EXCAVATE&TREAT(ET) PUMPS TREAT GROUNDWATER(GT)O REPLACE SUPPLY(RS) <br /> w� <br /> CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) O VENT SOIL(VS) <br /> VACUUM EXTRACT(VE) OTHER(OT) <br /> (�Zik �► -` <br /> NSC OS IAsq <br />