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uST <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENCY USE ONLY <br /> REPORT BEEN FILED 7 I HEREBY CERTIFY.THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT HAVE <br /> F-1ES �NO [:]YES NO REPORTED THIS:INFORMATION TO.LOCAL,CFFICIALS.PURSUANT TO SECTION 25180.7 OF <br /> REPORT DATE THE HEALTH AND SAFTY CODE. <br /> M T M -3 D "1 y ;qCASE# <br /> SIG D t' �DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONESIGNATURE <br /> > \j I C_ C,h car v-,r--V-\ (916)4Sz-Z 891 <br /> o REPRESENTING � OWNERIOPERATOR O REGIONAL BOARD COMPANYOR AGENCY NAME Ell <br /> �(l <br /> 0O ElE LOCAL AGENCY OTHER L,/I��-(LH j�((�/L� V(2L AJ HS4,I'V4L— <br /> w <br /> ADDRESS �/l ��/� /�� 9,S-8 <br /> /J� <br /> STR � _"`coctj�f}p-1 L 1�/ CA SPATE ZIP <br /> / �8 Y/ <br /> NAME CONTACT PERSON PHONE <br /> co + <br /> Z Q CAVY\C�5 l Sk ❑ UNKNOWN (z () 9 ez: —09�* <br /> g Qa ADDRESS <br /> Q <br /> STREET CITY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ,S It L. KAo-,r-kc:+- �'3 Cx\c b F-7I (zcq)9 sz-o9 8--F <br /> < ADDRESS _ _ c( ; <br /> ITREET CITY <br /> yCROSS STREET TYPE OF AREA COMMERCIAL INDUSTRIAL RURAL TYPE OF BUSINESS mil RETAIL FUEL STATION 1KA <br /> �{ r l RESIDENTIAL ❑OTHER ❑ FARM F--] OTHER l <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> 4� <br /> 033 5 <br /> to hyo ( - <br /> W w REGIONAL BOARD PHONE <br /> CL <br /> v� <br /> (1) NAME QUANTITY LOST(GALLONS) <br /> �u I�—�SQ(r i L UNKNOWN <br /> J <br /> (2) <br /> ❑ UNKNOWN <br /> z DA/TE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> M / M C1.18.1 v _S—y ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN ❑ REMOVE CONTENTS -�<REPLACE TANK ❑ CLOSE TANK <br /> cr <br /> w M M D 0 Y Y �` <br /> p HADISCHARGE❑BEENIOSTO YES,DATE /M � M �DIE D � v �--- ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> c� �l y OTHER <br /> w SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> cn <br /> ❑ TANK LEAK ❑ UNKNOWN GAL. FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE <br /> v K PIPING LEAK AGE YRS ❑ STEEL ❑ CORROSION UNKNOWN <br /> cc ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w w CHECK ONE ONLY <br /> ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ON'ONLY <br /> Q y a SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) F-] CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> L)N ❑ 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 /> o O ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> w� ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE 6 TREAT(ET) ❑ PUMP 6 TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> �, t✓�ra-f-6� cr' x ecx,u(zfiGn I"c cl(,I <br /> w <br /> HSC 051 <br />