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qo <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)l CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGE SERVICES FOR LOCALAGENCY USE,ONLY <br /> REPORT BEEN FILED? 1 HEREBY:CERTIFY THAT t AM A DESIGNATE(!GOVERNMENT"EMPLOYEEANDTHAT E HAVE <br /> a YES NO YES NO REPORTED.:THIS INFORMATION.TO LOCAL OFFICIALS PEIRSUANT TO SECTION 25180 T OF, <br /> REPORT DATE CASE x THE HEALTH D SAFTXCODE <br /> � <br /> ��MI SMI v 7 - 'DI YI OY $I�iNEB ;; DATE. <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> Cel <br /> Lu <br /> REPRESENT ❑ OWNER/CPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME <br /> LOCAL AGENCY ❑ OTHER , �� �� !j / -1 S'P/ vt Cz'S <br /> CL <br /> 2 ADDRESS <br /> / Z�TREET /, v e Cf TY 1Y5 VAI STATEe—A �ZIP / <br /> Lq NAME �/ _ CONTACTPERSON PHONE <br /> In /t/ f S. �//'/ ❑ UNKNOWN �EP� /0 <br /> CIL, S"FA <br /> ��5 //(C!/ EET ✓l I C1TY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ADDRESS <br /> w <br /> CRY ! - V COUNTY Gfi Q L.1 G <br /> ~ CROSS STREET TYPE OF AREA ❑ TYPE OF BUSINESS ❑ <br /> y COMMERCIAL INDUSTRIAL RURAL RETAIL FUEL STATION <br /> =RESIDENTIAL =OTHER O FARM = OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> y <br /> w w REGIONAL BOARD PHONE <br /> y (�) NAME OUANTTTY LOST(GALLONS) , <br /> w0 <br /> J <br /> /fin P NKNOWN <br /> 0 (2) F� <br /> y all E, NKNOWN <br /> Z <br /> DATEDISCOVERED / HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING p NUISANCE CONDITIONS <br /> 0�D Y I Y ❑ TANK TEST a TANK REMOVAL a OTHER <br /> /a- DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK THAT AP Y) <br /> ? UNKNOWN REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> cur M D D Y Y <br /> HAS DI ARGE BEEN STOPPED? ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> p YES ❑ NO IF YES,DATE MI MI D D v Y ❑ OTHER <br /> w SOURCE OF OISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSES) <br /> ❑ TANK LEAK UNKNOWN l�t7� GAL. ❑ F LASS O OVERFILL Q FI AILURE <br /> Q ❑ PIPING LEAK AGE YRS �4 STEEL ❑ CORROSIONUNKNOWN <br /> ❑ OTHER UNKNOWN Q OTHER ❑ SPILL ❑ OTHER <br /> w w CHECK ONE ONLY <br /> U ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONr ONLY <br /> zN <br /> cc <br /> ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> v 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 /> ozz ❑ CAP SITE(CD) ❑ EXCAVATE 3 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> Lu <br /> ❑ CONTAINMENT BARRIER(C8) ❑ EXCAVATE&TREAT(ET) ❑ PUMP 6 TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(HIM ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> f s/ �CssPss vc w;!/ �� .�cr!ss 6 � e�,.h�wv <br /> z <br /> `° <br /> w <br /> �C'o�� .-,T���cn cis ����r�!«f dy �4 lv� r���l��� a�P•� ��'. <br /> NSC OS(4ffn <br />