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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 /> REPORT BEEN FILED 7 1 HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> ❑ YES �NO YES ❑ NO <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT DATE CASE i <br /> 0M / MI U v SIGNED DATE <br /> m <br /> NAME OF IND IDU FIGLCIN'GREPOB� PHONE SIGNATURE <br /> Lu REPRESENNTING71 ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY <br /> COMPANY OR AGENCY NAME <br /> LOCAL AGENCY ❑ OTHER <br /> ADDRESS Qi 6 e t 1 O O r <br /> STREET CTI STATE ZIP <br /> Lu NAME j� fiC CONTACT PERSON PHONE ' C� <br /> N (J �� 1 J r ❑ UNKNOWN " ) J / <br /> w a AD SS 1 �. / O 3 Ar/9��s�19 <br /> fT) CFJi (p STREET CITY STATE p G 6 <br /> PHONE <br /> FACILITY NAME(IF APPLICABLE) 1 OPERATOR <br /> ° <br /> UADDRESS „• �`�` �•��� <br /> w SIRE CITY COUNTY 21P <br /> CROSS TgEET <br /> } l If h- <br /> LOCAL AGENC AGENCY NAME CONTACT PERSON PHONE <br /> w w REGIONAL BOARD PHONE <br /> CV <br /> y (1) NAME QUANTITY LOST(GALLONS) <br /> wp <br /> z>� B ❑ UNKNOWN <br /> Q J <br /> H <br /> CO>) (2) <br /> D Z <br /> ❑ UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED F-1INVENTORYCONTROL ❑ SUBSURFACE MONITORING El NUISANCE CONDITIONS <br /> z <br /> w �MI SMI O DI DI vi,, sv ❑ TANK TEST [:] TANK REMOVAL OTHER ' <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT AP Y) <br /> a <br /> UNKNOWN ❑REMOVE CONTENTS [:]CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> w M M D D Y V <br /> 0 HAS DISCHARGE BEEN STOPPED Z ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> o ❑ YES NO IF YES.DATE ❑REPLACE TANK OTHER <br /> M MI D D Y Y <br /> SOURCE OF ISCH RGE CAUSE(S) <br /> w <br /> ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> 0° ❑ PIPING LEAK FBOTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> w w CHECK ONE ONLY <br /> n a <br /> ° ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> w <br /> cr� LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> ° ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> J (SEE SACK FON MALS) <br /> a z ❑ <br /> O CAP SITE(CD) F-] 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) <br /> ❑ VACUUM EXTRACT(VE) OTHER(OT) �- iS <br /> IV <br /> U) <br /> u'll't S 60. <br /> CALc� f�� rt• c� �fi - C <br /> HSC 05(650) <br />