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f� <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 ZO REPORT BEEN FILED 7 ❑ YES ❑ NO 1 HEREBY CERTIFYTHAT 1 HAVE DISTRIBUTED THIS INFORMATION ACCORDING TOTHE <br /> DISTRIBUTION SHOWN ON.THE INSTRUCTION SHEET.ON THE BACK PAGE OF.THIS FORM <br /> REPORT DATE 7/ y <br /> CASES <br /> M MI/ ` �SIGNFD f/ �j :. DATE.. <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> m <br /> � REPRESE G ❑ OWNER/OPERATOR ❑ <br /> REGIONAL BOARD COMPANY OR AGENCY NAME <br /> cr. ET LOCAL AGENCY ❑ OTHER �Q C/ h 6 <br /> ADDRESS <br /> STREET CRY STATE ZIP <br /> w NAMEco <br /> / / _ CONTACT PERSON //-- PHONE / <br /> zr �`� � JcfnG` G/heSAlC-DUNKNOWN sijlVlL / }L�S � { 60 <br /> a a ADDRESS <br /> wCL <br /> lai s- <br /> cc <br /> STREET cm STATE zip <br /> FACILITY NAME(IF APPLICABLE) / OPERATOR ` PH NE <br /> p G�r� v1JG!/� 11 �l/'7G`S �KC, GI/v/� /1 ( W" <br /> a ADDRESS <br /> ef��/f��'7 <br /> UJ STREET CITY COUNTY <br /> v~Ji CROSS STREET <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> Wv <br /> w w REGIONAL BOARD PHONE <br /> CL <br /> J C7 <br /> U3 (1) NAME QUANTITY LOST(GALLONS) <br /> w� <br /> 2 w <br /> ,e- <br /> ;!E S�` NKNOWN <br /> J <br /> m'> (z) <br /> Dz <br /> ❑ UNKNOWN <br /> z <br /> DATE DISCOVERED HOW DISCOVERED ❑ INVE YTONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> wL/MI MI o"15 DI gYI r ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> m <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP HA (CHECK ALL THAT APPLY) <br /> c <br /> UNKNOWN ❑REMOVE CONTEN S SE TANK 8 REMOVE REPAIR PIPING <br /> w M D D Y Y <br /> p HAVDIS HARGE BEEN STOPPED? \ Q ❑REPAIR TANK OSE TANK b FILL IN PLACE ❑CHANGE PROCEDURE <br /> ES ❑ NO IF YES.DATE I D J� lv r ❑REPLACE TANK ❑ OTHER <br /> SOURCE OF DISCHARGE CAUS (S) <br /> UJ <br /> U) ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> N v ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> LU w CHECK t0ONLY <br /> N a ETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> cc <br /> cc <br /> ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> v ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY i <br /> CHECKAPPROPRIATE ACTION(S) ❑ EXCAVATE 3 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BID DEGRADATION(IT) <br /> J (SEE BACK FOR WYA&SJ <br /> a Z <br /> 00 ❑ CAP SITE(CO) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) f� <br /> ¢ ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> e s s.--e�N ttit // eZ.� YLR-C Ps,J-GZ-c./ To �C , .a..r i:-..a f�•-� �z c�fGuC <br /> LLJcrKo/ e.r�t7f uli-�el �L/1-11,e <br /> HSC 05(wm <br />