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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> F-1 YES YES �O RTI <br /> REPORT BEEN FILED 9 I HEREBY CEFYTHAT i HAVE DISTRIBUTED THIS INFORMATION ACCORDING TOTHE <br /> dN0 ❑ <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORMA <br /> REPORT DATE CASE X <br /> 0m2 /�/fMI `� y 7_5 SIGNED - DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> Lu REPRESENTING OWNERIOPERATOR ❑ REGIONAL BOARD COMPANYY ORR AGENCY NAME <br /> p ❑ LOCAL AGENCY ❑ OTHER `_ �,9p' . <br /> Ir ADDRESS V [JUx 6,0M r�/�-/ .d'l� �107G'.140 <br /> STREET CITY STATE ZIP <br /> J NAM A ,/� /► ,r �,a <br /> cw ��W//L�Cil cJn ❑OGGONNTATACTfPERSON <br /> ,�, r � PHONE <br /> WN ON�IUNKNO ��z cc <br /> a¢W(L ADDRESS D/vO J <br /> w Ar,—`t "o— 64 <br /> 91d G <br /> STREET CITY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> z /fRC�vr�i�i ,j�(�lv� hli¢?i117 'T ( 5-777 <br /> OI/2 ADDRESS K l�/ /:� �J P/ 7 Y�Y � ! ✓/�i� S//T J1� � LL /J ! 'Y <br /> J <br /> w STREET CITY COUNTY Zip <br /> CROSS STREET <br /> 0 LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> z NUC�u� .:v/c t��✓ <br /> Lu U <br /> w w REGIONAL BOARD PHONE <br /> J U <br /> a <br /> W (i) NAME QUANTITY LOST(GALLONS) <br /> W o n.��,., f�//(l/ <br /> a J `9 n dvZ"/4, � / UNKNOWN <br /> m (2) <br /> U ❑ UNKNOWN <br /> Z DATE DISCOVER 7, <br /> , HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> w o I ( o� o1 7,Y y [:] TANK TEST ❑ TANK REMOVAL OTHER31 <br /> m DINE DARGBEG;N METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Q31 O UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE E::]REPAIR PIPING <br /> Lu <br /> M M D D Y Y <br /> HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑�1CHAGNGE PROCEDURE <br /> ON YES ❑ NO IF YES,DATE I " D 7Yi Y E::]REPLACE TANK Q OTHER �OG7w/V <br /> 0 <br /> La w SOURCE OF DISCHARGE CAUSE(S) <br /> U) <br /> ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> �NS�• J <br /> a ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN [Zr OTHER0,4-- ( &orJ" <br /> w w CHECK ONE ONLY <br /> U�7 ❑ UNDETERMINED ❑ 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 I- ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY E:] POST CLEANUP MONITORING IN PROGRESS <br /> U� <br /> ❑ REMEDIATION PLAN © CASE CLOSED(C6G" IIP r^"PIF ^^ err rn I') ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> J (SEE BACK FOR DETALS) <br /> E5 0 ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w� <br /> w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) E:] VENT SOIL(VS) <br /> ¢ ❑ VACUUM EXTRACT(VE) OTHER(OT) (AH/ �( � /�/o/�'OZ' �� /} j"t 5',bVfPA1V-DolJ <br /> . ) . i*/.bocn <br /> .• <br /> 66 <br /> ui <br /> F E 6 16 1999 <br /> X y4,6- ENVIRONMENTAL HEALTH HSC 05(a'gq <br /> PERMIT/SERVICES <br />