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a <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />FOR LOCAL AGENCY USE ONLY <br />REPORT BEEN FILED ? <br />❑ YES No YES ❑ <br />1 HEREBY CERTIFY THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE :AND THAT k HAVE <br />REPORTED; THIS INFORMATION :TO LOCAL OFFICIALS PURSUANT TO SECTION 251807 OF <br />iH6 H! ANQ SALTY <br />REPORT DATE <br />CASE <br />M D DY Y <br />:� DATE <br />NAME OF INDIVIDUAL FILING Re -PORT <br />PHONE <br />SIGNATU <br />m <br />- <br />REPRESENTI G ❑ OWNER/OPERATOR ❑ REGIONAL BOARD <br />[]%PA)Ny OR AGENCY NAME <br />O <br />OCALAGENCY ❑ OTHER <br />j� <br />a <br />2 <br />ADDRESS <br />JCr7y <br />n� � • V V �� <br />Cy/.- � /7�-C.,�LSI STATE ZIPC/ <br />NAME <br />CONTACT PERSON <br />E <br />M¢ <br />EJUNKNOWNG <br />L <br />/PHON(/' 3 <br />\'R/b) Z 1 <br />Qa <br />ADDRESS <br />-BTREE✓' (TY STATE ZIP <br />FACILITY NAME (IF APPLICABLE) <br />OPERATOR <br />PHONE <br />F <br />ADDRESS <br />TREET CffY COUNTYZIP <br />y <br />CROSS STREET <br />., <br />TYPE OF AREA ❑/COMMERCIAL ❑ INDUSTRIAL ❑ RURAL <br />TYPE OF BUSINESSETAIL FUEL STATION <br />, L1-06 <br />I [:]RESIDENTIAL 0 OTHER <br />❑ FARM ❑ OTHER <br />LOCAL AGENCY AGENCY NAME <br />CONTACT PERSON <br />PHONE <br />z w <br />164C 0i L S <br />T1J <br />2� 3�f Zl <br />w <br />REGIONAL BOARD <br />PHONE <br />(1) NAME QUANTITY LOST (GALLONS) <br />ZvUNKNOWN <br />Q J <br />~ O <br />(2) <br />D❑ <br />UNKNOWN <br />F <br />DATE DISCOVERED <br />HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br />z <br />2 <br />/J /J <br />/ M / D D 'g, v <br />TANK TEST ❑ TANK REMOVAL ❑ OTHER <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />QUNKNOWN <br />❑ REMOVE CONTENTS ❑ REPLACE TANK E] CLOSE TANK <br />w <br />p <br />M M D D Y Y <br />TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br />HAS❑DISCY E BEEN T <br />SRG❑ NO IOF YES, DATE M M p p y y <br />❑ OTHEIR <br />u� <br />4 <br />SOURCE OF DISCHARGE <br />❑ TANK LEAK N� UNKNOWN <br />TANKS ONLY/CAPACITY MATERIAL <br />i (J� V GAL. FIBERGLASS <br />CAUSE(S) <br />❑ OVERFILL ❑ RUPTURE/FAILURE <br />❑ PIPING LEAK <br />AGE �_ YRS ❑ STEEL <br />❑ CORROSION UNKNOWN <br />2 <br />❑ OTHER <br />❑ UNKNOWN ❑ OTHER <br />❑ SPILL ❑ OTHER <br />w w <br />CHECK ONE ONLY <br />0 <br />UNDETERMINED ❑ SOIL ONLY 0 GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />F <br />CHECK ONE ONLY <br />a <br />❑ SITE INVESTIGATION IN PROGRESS (DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) <br />cc <br />U y <br />❑ 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 />oO <br />❑ CAP SITE (CD) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) <br />wP ❑ <br />CONTAINMENT BARRIER (CB) ❑ EXCAVATE & TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />❑ TREATMENT AT HOOKUP (HU) ❑ NO ACTION REQUIRED (NA) ❑ OTHER (OT) <br />lZ' Hsi 1 MEm' <br />W <br />4 Ec�� r of CoNTr9 m1Al&77v1u, /2 , ,;a--Quaep av TNS &WRQ op/nE7 lir c <br />2 <br />