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9 /-Ltss <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGE Y SERVICES FOR LOCAL AGENCY USE ONLY '. <br /> REPORT BEEN FILED 2 I HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> ❑ VES NO YES ❑ NO <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORTDATE / CASE• <br /> OM `✓M / • r SGKED DATE ` <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURES <br /> �?D9� ln�= 3Y3 <br /> w REPRESE NG OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> gLOCALAGENCY O OTHER SA-co P t-fs — L / <br /> ADOP�5N0� oZoo ff47!✓�- C T5ad/ <br /> . <br /> 3lREEf cm STAre nv <br /> w� NAME <br /> l/ ' OCONTACTPERSON PHONEForest- Pr(Q CONTACTPERSON <br /> I <br /> Plae--L 61d z/ �u�t3ss, ,fie Oso c7 ,e 47a 5 <br /> STIR cm sTare w <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> icww ` d I ( ) <br /> Q ADDRESS1� ' � �� � <br /> Ij1 <br /> l R s�- 4.a4'V- S <br /> g'� w <br /> {Q�>Y S� c( A 05 <br /> �REw <br /> y CROSSSTREET <br /> MarshaI I <br /> O LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> w LS �� S — E HID L ifi ` w �S �, b�i)Yb?'3Y3T <br /> w REGIONAL BOARD /^ /� PHONE <br /> n a R c yam[ <br /> y (1) NAME QUANTITY LOST(GALLONS) <br /> Q <br /> <J ❑ UNKNOWN <br /> M Z (2) <br /> �- <br /> `A ❑ UNKNOWN <br /> i /DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ UBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> w !/ u `r u� kj oo� r / r ❑ TANK TEST O TANK REMOVAL OTHERdr <br /> p(�� <br /> m DATE DISCHARGE BEGAN / METHOD USED TO STOP DISCHAR (CHECK ALL T APPLY) <br /> a u D r v ^LIXLI/NKNOWN ❑REMOVE CONTENTS O CLOSE TANK B REMOVE O REPAIR PIPING <br /> HAS DISC GE BEEN STOPPED 4 O REPAIR TANK OCL E TANK&FILL IN PLACE O CHANGE PROCEDURE <br /> o VES O NO IF VES,DATE O.I (aMI 'Q0 0 ?r / r ❑REPLACE TANK OTHER r <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> D ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL RUPTURF/FAILURE ❑ SPILL <br /> hO PIPING LEAK ❑ OTHER FR<DRROSION ❑ UNKNOWN ❑ 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 ❑ NO ACTION TAKEN O PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED E:] POLLUTION CHARACTERIZATION <br /> ¢r Fo<EAK BEING CONFIRMED O PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O y REMEDIATION PLAN O CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) O ENHANCED BIO DEGRADATION(IT) <br /> w0 [CADaul <br /> a� r CAPP SITE <br /> (CCD) E:] EXCAVATE 8 TREAT(ET) ❑ PUMP A TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w a ❑ CONTAINMENT BARRIER(CB) ❑ ACTION REQUIRED(NA) ❑AT-RE-ATTMJ NT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> m ❑ VACUUM EXTRACT(VE) OTHER(OT)4 S.SeS S yn,WW <br /> i�►'qv a�I7�2 T�� TGIin�.�01- a /'JiYrWvc�C_ <br /> a S r - a- ca.4 <br /> HSC <br />