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t <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EME=RGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> YES NO REPORT BEEN FILED? ❑ YES ❑ NO I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.1 OF <br /> n^E"OR f DATE �J CASE i �����'!� O/O�,O / <br /> l'u u� O d OZo' Q vI v SIGNED <br /> DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE IGH RE-� <br /> ten <br /> w REPRESENTING F7OWNER/OPERATOR � REGIONAL BOARD COMPANY OR AGENCY NAME n <br /> 2 LOCALAGENCY ❑ OTHER <br /> ADDRESS <br /> ^_^ ,b •� /� �O I STREET GlU GTr 094 STATE <br /> ZIP <br /> NAME CONTACT PERSON PHONE <br /> adq) YA <br /> 3-33/Z Q <br /> S< ADDRESS <br /> ui <br /> �RL1E 1 A.W 1.T"'�•^�`� CRY �-! 1 STATE(?e 3 (/ ZIP <br /> FACILITY NAME(IF APP LE) OPERATOR PHONE <br /> ADDRESS �` <br /> W <br /> I� ?_W��•�4. 1 ' t.LY� ISS✓ Cm v(L.V���-L Lll ✓j courm 96733 zip <br /> CROSS STREET TYPE OF AREA ❑ ❑ ❑ TYPE OF BUSINESS <br /> a� COMMERCIAL INDUSTRIAL RURAL RETAIL FUEL STATION <br />_� ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> , / <br /> w <br /> REGIONAL BOARb PHONE <br /> CL <br /> (1) NAME QUANTITY LOST(GALLONS) <br /> N �l e��"r�e CkA l <br /> Lu <br /> UJ <br /> U UNKNOWN <br /> 0'i ;2) <br /> co Z. <br /> D UNKNOWN <br /> i DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> ~} w /.I al I D 0 8v� 8 Y ❑ TANK TEST ❑ TANK REMOVAL ❑ OTHER <br /> r <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK CLOSE TANK <br /> w M M D D V V <br /> W <br /> HAS DISCHARGE BEEN STOPPED? 1`',�N (❑ REPAIR TANK � REPAIR PWG CHANGE PROCEDURE <br /> YES ❑ NO IF YES,DATE <br /> O <br /> u rAI o1 o1 vj r LpJ OTHER <br /> J w SOURCE OF DISCHARGE TANKS ONLYrAPACITY MATERIAL CAUSE(S) <br /> J ❑ TANK LEAK UNKNOWN GAL. ❑ FIBERGLASS ❑ OVERFILL RUPTURE/FAILURE <br /> Uu ❑ PIPING LEAK AGE YRS ❑ STEEL CORROSION UNKNOWN <br /> ❑ OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> ' CHECK ONE ONLY <br /> _I na <br /> `-'(+ v� ❑ UNDETERMINED ❑ SOIL ONLY � GROUNDWATER ❑ DRINKING WATER• (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> L Z N <br /> ` Lu Q a SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> �oOJ� cc <br /> V y ❑ NO ACTION TAKEN D POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED [�] EVALUATING CLEANUP ALTERNATIVES <br /> (� CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> v o zz CAP SITE(CO) EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> w c� F CONTAINMENT BARRIER(CB) ❑ EXCAVATE 6 TREAT(ET) ❑ PUMP 8 TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> 1/ <br /> ❑cc TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) � OTHER(OT) <br /> Cl- U C6v <br /> -' W ,,� r ,� fie, c,e�r�aL•� c lv <br /> 7:5 4 '2 ,A, <br /> HSC 05(447) <br />