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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED 91 HEREBY CERnF.YTkAT!HAVE DISTRIBUTED7lil5.WFbRMOON ACCORDING i07NE <br /> ❑ <br /> YE ❑ YES NO <br /> (]IS7Ri6[}TKk(.SHOWN:ONT} INSTRUCT)ONSHEATONTHEBACKPAGEDFTHISFOR_K <br /> REPORT DATE CASE• <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> >_ t (Uri) g16Y-4 y`� <br /> w REPRESS ING REGIONAL BOARD COMPANY OR AGENCY NAME <br /> ❑ OWNEFVOPERATOR ❑ <br /> aLOCALAGENCY ❑ OTHER jya <br /> cc ADDRESS <br /> [!�/� V• EtT / \v 11Jrr1,1--q"CC/�ITMiI STATE +3 2,01-IIP <br /> W NAME CpNTACTPERSON PHONE <br /> Z ❑ UNKNOWN 1 <br /> 0a ADQRESS `{ s7i� <br /> w �A .l f <br /> ¢ ` �- CRY STATE ZIP <br /> FIACILITY NAME(IF APPLICABL OPERATOR PHONE <br /> z: <br /> O <br /> v <br /> ADDRESS <br /> r 4 /�-L, 1 <br /> 0. Y I lCITY C�IfAVHT„ q 5 ;-f <br /> W <br /> ~ CROSS STREET <br /> Q LOCAL AGENCY AGENCY NAME CONTACT PERSON rPHONE <br /> z N 1 ) <br /> Z tu W <br /> w w REGIONAL BOARD PHONE <br /> CL <br /> {t} NAME QUANTITY LOST(GALLONS) <br /> LU <br /> 0 �{ ❑ UNKNOWN <br /> =w a <br /> H J <br /> vt Oy (2) <br /> Ejy f <br /> UNKNOWN <br /> DATE DISCOVERED HOW DISCOVERED E] INVENTORY CONTROL F-1RFACE MONITORING E:1NUISANCE CONDITIONS <br /> Z <br /> f` TANK TEST TANK REMOVAL FKT <br /> OTHER <br /> 3„ , Q Y Y <br /> m DATE DISCHARGE BEGAN METHOD USED TO <br /> Is <br /> DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE REPAIR PIPING <br /> w M D Y <br /> p HAS D1SCH AGE BEEN STOPPED Y ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> "—� YES ❑ NO IF YES,DATE '� MI C>n ` © Y ❑REPLACE TANK ❑ OTHER <br /> a <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> w <br /> ¢� Ej TANK LEAK UNKNOWN ❑ OVERFILL Q RUPTUREIFAILURE ❑ SPILL - <br /> 9)0 ❑ PIPING LEAK ❑ OTHER ❑ CORROSION Ejj >NKNOWN ❑ OTHER <br /> Lu w CHECK ONE LY <br /> In CL <br /> U UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w ❑ NO ACTION TAKEN ❑ ELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> LEAK BEING CONFIRMED �PRRELlMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U.N <br /> ❑ <br /> REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> ssfi sAC,A FOR WTA M <br /> a x CAP SITE(co) ❑ EXCAVATE a TREAT(ET) ❑ PUMPS TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> p0 <br /> W~ NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU} ❑ VENT SOIL(VS) <br /> w 4 ❑ CONTAINMENT BARRIER(CB) ❑ ❑ <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> i <br /> y ' <br /> H <br /> X <br /> W <br /> �OQ <br /> S.1 <br />