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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LCA T40,14TAMINATfiON SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL;A CY US 18 �' <br /> REPORT BEEN FILED 7 RTi RQ <br /> ❑ YES ❑ NO ❑ YES ❑ No 1 HEREBY CE DIST U& ORh��i710N ACCORDING TO THE <br /> DISTRIBUTION SHOWN_ ILON S N THE BACK PAGE OF THIS FORM. <br /> REPORT DATE CASES ¢� l <br /> M M / v SIGNED " R `� I`j i; DATE <br /> NAME OF INQIVIDUAL FILING REPORT PHONE SIGNATURE <br /> ti <br /> w REPRESENTING OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> g ❑ LOCAL AGENCY ❑ OTHER <br /> Lu <br /> ADDRESS :L'H4+ t W t v.-�C7r\ t��� i�T G�� J%-' ,� C/� <br /> STREET CITY STATE ZAP <br /> J NAME CONTACT PERSON PHONE <br /> C.1 �o t <br /> co UNKNOWN <br /> z¢ .. <br /> M< ADDRESS q _© <br /> m at^x t 7 1/\ <br /> w <br /> [L <br /> STREET CIT' STATE 71P <br /> FACILITY NAME(IF APPLICABLE) �j -OPERATOR PHONE <br /> zo V I`E(f,�, \ .«sQ/u 1 C J( �t �6'O 7 <br /> U ADDRESS r kA <br /> Lu <br /> STREET CITY COUNTY <br /> y CROSS STREET <br /> !/1 ` ziP <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> z0) <br /> w <br /> 11 1`, <br /> w w REGIONAL BOARD PHONE <br /> CL <br /> \'1; <br /> W (1) NAME QUANTITY LOST(GALLONS) <br /> O <br /> J Gr v\.( ❑ UNKNOWN <br /> In m (Z) <br /> �z � <br /> 0 . ' ❑ UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> M� r M D D� v � v ❑ TANK TEST ❑ TANK REMOVAL ❑ OTHER <br /> am DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> Ir M M D D r v ❑ UNKNOWN E]REMOVE CONTENTS �CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> 0 HAS DISCHARGE BEEN STOPPED? -1REPAIR TANK E::]CLOSE TANK d FILL IN PLACE ❑CHANGE PROCEDURE <br /> U <br /> ❑ YES ❑ NO IF YES,DATE <br /> M MI D D V Y ❑REPLACE TANK [:j OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> uJ <br /> j a ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> U ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> w wa CHECK ONE ONLY <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 ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> j ti ❑ LEAK BEING CONFIRMED F-1PRELIMINARYSITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> Q ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> J ISEE fl FON DETAtS) <br /> a z CAP SITE(CD) EXCAVATE&TREAT(ET) PUMP 6 TREAT GROUNDWATER(GT) <br /> w O <br /> ❑ ❑ ❑ ( ❑ REPLACE SUPPLY(RS) <br /> Lu a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) OTHER(OT) <br /> � • ..'�f i .. c.- t...���y� <br /> ` Fr 4 Q '.u4 r a ti .� G G.4 - t ,� U.4a �•�.D i P <br /> o <br /> HSC 0518/90) <br />