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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY S7NC <br /> FOR LOCALAGENCY USE ONLY <br /> REPORT BEEN FILED 7 I HEREBY.CERTIFY THAT I AMA DESIGNATED GOVERNMENT.EMPLOYEES AND TWAT 1 HAVE. <br /> ❑ YES �NO ❑YES REPORTED THIS;INFORMATION;TO UDCAL OFFCCIALS PURSUANT TO SECTION 2$1807 OF: <br /> REPORT DATE 7�y, <br /> ASE a THE HEALTH CIS .Y E <br /> M M OY SONEjE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE <br /> PHONE Lam/ G C� SIGNATURE —!//-�/-�1 /r✓�7�, ,, I <br /> m <br /> I,'/ f Q TIDO - /y O�u�:�V✓--'C�' / -C�>�. <br /> a REPRESS G F—] OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME ['o <br /> ¢O LOCAL AGENCY E] OTHER Sam ��G (�v k4 c ���J (t-al flv N <br /> a <br /> ADDRESS <br /> E . s e/- A <br /> CRY STATE ZIP <br /> NAM j� 4 CON/T�ACTPERSON y / PHONE <br /> in z / v '' /' ��G� ��//�, �I�G�G�f I'1 ❑ UNKNOWN L (�C�/"C���'�/P!/�f c�9)y��l�5a(, <br /> Qa <br /> ADDRESS <br /> W i �' S to f11 13rcj59os <br /> STREET CRY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> 11, y , o f��1 rr u6e, ji ,EcIajo r� CG;v fPlr,' 001) <br /> f <br /> ADDRESS (r <br /> Rh G �crry COUNTY P <br /> hCROSS STREET TYPE OF AREA ❑COMMERCIAL INDUSTRIAL❑RURAL TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> ❑RESIDENTIAL ❑OTHER ❑ FARM MOTHER <br /> LOCALAGENCY AGENCY NAM CONTACTPERSON PHONE <br /> Z W 1 cl A-10C l u <br /> w REGIONAL BOARD PHONE <br /> LPN <br /> �G <br /> y (�) NAME QUANTITY LOST(GALLONS) <br /> L,U 0 .S fe- o / ❑ UNKNOWN <br /> o (2) <br /> y ❑ UNKNOWN <br /> r DATE DISCOVERED Q HOW DISCOVERED ❑ INVENTORY CONTROL PU8SURFACE MONITORING NUISANCE CONDITIONS <br /> M •M D DD �v V v ❑ TANK TEST ❑ TANK REMOVAL THER <br /> g DATE DISCHARGE BEGAN METHOD U ED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> QUNKNOWN REMOVE CONTENTS ❑ REPLACE TANK OSE TANK <br /> W M M D D Y Y <br /> > HAS DISCHARGE BEEN STOPPED? ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> p �ES ❑ NO IF YES,DATE M M D DI <br /> v y ❑ OTHER <br /> (w SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK UNKNOWN GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE <br /> Q ❑ PIPING LEAK AGE YRS ❑ STEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER UNKNOWN OTHER ❑ SPILL ❑ OTHER <br /> w wa CHECK ON ONLY <br /> v UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F, CHECK ONLY <br /> zN <br /> a SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> u y ❑ 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 [—] CAP SITE(CD) ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(M <br /> w� F—] CONTAINMENT BARRIER(CB) ❑ EXCAVATE 6 TREAT(ET) 9/0MP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ¢ E] TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) THER(OT) <br /> Lu bo r a +o rTe S t S o h Sa% l Sh o�v C-," ~a-m i vt Ql't0K,, u r t lug <br /> W ,_S�i`f� << S S P�vw i r l b e l'P u r re c( fo CQ�-FP r Wt <br /> 8 '(,t r v.� �?-'�f'� �` -F C0-o cz-"�-L,� chi` j ar S PLO ' (,t i ✓`e t by <br /> y <br /> cLpprf,) p /', e QJ " Hscm("n <br />