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-01 a <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 REPORT BEEN FILED? I HEREBY CERTIFY THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> ❑ YES NO <br /> REPORT DATE REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> CASE# THE HEALTH AND SAFTY CODE. <br /> / M M l/p (-D �Y Y SIGNED— — <br /> NAME OF INDIVIDUAL FILING REPORTDATE' <br /> PHONE SIGNATURE <br /> > 4ADDRESS <br /> �2Le,�� �N f t (70 ) �V7,o <br /> ESENTING <br /> ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> Cc <br /> IPTLOCAL AGENCY ❑ OTHER s �` � <br /> ¢ <br /> SADDRESS <br /> 6 StU <br /> CONTACTPERSON srATEZiP <br /> co rPHONE <br /> ❑ UNKNOWN I)n'- Kj> -cL ! .Z Q j fad �D <br /> BEET <br /> FACILITY NAME(IF APPLICABLE) STATE ZIP <br /> R C <br /> OPERATOR <br /> CRV <br /> g PHONE <br /> ADDRESS <br /> gbSi L(NV ETRE L(��:� L✓��� ��ZC! <br /> y CROSS STREET TYPE OF AREA Cay P <br /> COUNTY II <br /> COMMERCIAL ❑ INDUSTRIAL ❑RURAL TYPE OF BUSINESS <br /> ❑RESIDENTIAL ❑OTHER ❑ RETAIL FUEL STATION <br /> ❑ FARM OTHER <br /> yl yz <br /> rH <br /> LOCAL'AGEN_Y AGENCY NAME CONTACT PERSON PHONE <br /> HY� � <br /> REGIONAL BOARD t2 <br /> C K u1 Q /^ <br /> _ �`,�(,� (may O I��O 17 �O S PHONE <br /> Wr(2 �/�� / NAME QUANTITY LOST(GALLONS) <br /> UNKNOWN <br /> ❑ UNKNOWN <br /> ❑ NUISANCE CONDITIONS <br /> HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING <br /> (J ( ❑ TANK TEST ❑ TANK REMOVAL ❑ OTHER <br /> METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> I�UNKNOWN v y l� ❑ REMOVE CONTENTS ❑ REPLACE TANK CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED? ❑ REPAIR TANK REPAIRPIPING❑ ❑ CHANGE PROCEDURE <br /> p YES ❑ NO IFYES,DATEM '? Sy C, y ❑ OTHER <br /> y SOURCE OF DISCHARGE TANKS ONLY/CAPACITY C� MATERIAL <br /> E:] TANK LEAK [OUNKNOWN j(� GAL, ❑ FIBERGLASS CAUSE(S) <br /> ❑ OVERFILL ❑ RUPTURE/FAILURE <br /> Q ❑ PIPING LEAK AGE YRS STEEL <br /> ❑ CORROSION UNKNOWN <br /> 2 ❑ OTHERUNKNOWN ❑ OTHER <br /> ❑ SPILL ❑ OTHER <br /> w W CHECK ONE ONLY <br /> CL <br /> U�- ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER• (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> zcn <br /> r a SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> N <br /> U ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> w z ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> 00 <br /> w ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER G <br /> ❑ ( T) ❑ REPLACE SUPPLY IRS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> `��� chis t'art�.u�Q r �„_ N nr�x,' , e u•,�C-� � ,c .�-�e ,/� <br /> z <br /> HSC 05(4)371 <br />