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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 /> �{ REPORTBEEN FILED? �/NO I.HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> F-1E Yes J NO ❑YES LJ REPORTED THIS.INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 251807 OF <br /> REPORTDATE CASEN THE LTH AND SAFTY CODE <br /> A� C t (,i <br /> I't <br /> vM aM 1 D 1 Y SIGN D DATE <br /> NAME OF INDIVIDUAL FILING REPORT SIGNATURE <br /> r14k I'C� ` . Cr-� AE��-LFNYORAGENCY <br /> ) Ll�g �` zo C"n I <« C <br /> REPRESENT( ❑ OWNEIVOPERATOR GIONALBOARD NAME <br /> 0 <br /> LOCAL AGENCY ❑ OTHER 70a LL1� <br /> 6 <br /> ADDRESSIto CL <br /> GGG11{YYY STATE zp <br /> NAME CONTACTPERSON PHONE <br /> ,1 p p <br /> UNKNOWN JZKp38,�3a- <br /> <y ADDRESS 5 (e.. e n-V <br /> () <br /> I� <br /> join g , K.. <br /> STREET CITY STATE ZIP <br /> FACILITY NAME(IFAPPUCABLE) r¢ ke, .DLA, OPERATOR PHONE <br /> a hr-T(A e'l, I PIn)�3t5�r�3 <br /> ADDRESS a C Z q <br /> ZL <br /> yCROSSSTREET TYPE OF AREA COMMEflCIAL❑INDUSTRIAL❑RURAL TYPE OF BUSINESS ❑ RETAIL FUELSTATION <br /> ur,L-- ❑RESIDENTIAL ❑OTHER ❑ FARMOTHER <br /> LOCALAGENCV AGENCY NAME CONTACTPERSON PHONE <br /> P: ja , �oci v n Lc 9 si f�,��C F L�(�Y3�I <br /> w REGIONAL BOARD PHONE <br /> (�) NAME OUANTRY LOST(GALLONS) <br /> LfCir6 CPQ( 0 11 Q2 UWNOWN <br /> (2) <br /> ❑ UNKNOWN <br /> DATEDISCOVERED Q HOWDISCOVERED ❑ INVENTORY CONTROL E:] SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> i <br /> M �D� D BY v ❑ TANKTEST YANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN LY) <br /> l METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APP <br /> i UNKNOWN ❑ E]REMOVE CONTENTS ❑ REPLACE TANK CLOSETANK <br /> M M D D Yl <br /> v r <br /> HASDISCHA EBEENSTOPPED? ❑ REPAIRTANK y ❑ REPAIRPIIIPIWGA. �-❑ CHANGE PROCEDURE <br /> o YES ❑ NO IFVES,OATE M M D D Y v R T uyo Uc 1 `�•� <br /> LLI SOURCE OF DISCHARGE TANKSONLYACAPAC)TY MATERIAL CAUSE(S) <br /> N� ❑ TANK LEAK UNKNOWN 1016o-0)Io CWU GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE <br /> ❑ PIPINGLEAK AGE YRS EL ❑ CORROSION UNKNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w� CHECKONEONLY <br /> ❑ UNDETERMINED SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> �h NOACTKXNTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TOPROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> ❑ CAP SITE(CD) ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(In <br /> 0 <br /> ❑ CONTAINMENT BARRIER(CB) ❑ IXCAVATEB TfiEAT(En ❑ PUMPS TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENTAT HOOKUP(HU) ❑ NO ACTION REOUIRED INA) ff� 7HER(OT) <br /> If /�hxrn� � , � ae _ l3 ! <br /> (�lx"1 moi✓^" ) 'L-Dl. d"�R n 'r,f fl" Of oa-v, <br /> Z C. CCL r2 <br /> Cli- <br /> HWW(4AM <br />