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.2 2 - az2� <br /> UNDERGROUND STORAGE MK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL`AGENCY USE ONLY <br /> REPORT BEEN FILED 7 i HEREBY CERTIFYTHAT 1.HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> F7YES NO ❑ YES .NO <br /> DISPABILITION SHOWN ONTHE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORK-': <br /> REPORT DATE] CASE a <br /> c�^� 1 <br /> to 2 MI ` I 1 1 v t 0 T`"� SIGNED DATE.:.. <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> m <br /> mots• ( 2DI) 4�,S 033 )14 <br /> w REPRESENTI ❑ OWNER/ PERATOR ❑ REGIONALSOARD COMPANY ORAGENCY <br /> y�N`A�ME ,gyp.,, <br /> p � LOCAL AGENCY ❑ OTHER �r�ll�r'�.+►.I��Ga�qVt� <br /> ¢ ADDRESS <br /> 30� lL WebC <br /> STREET CfT`F STATE ZIP <br /> J NAME {�^ n CONTTAACTPERSON \' PHONE p <br /> z �00 1 \ �i� ❑ UNKNOWN 1✓fib �e I`��Y�I�O <br /> a a ADDRESS <br /> I�iO33 1Ncs-I- vallq t-63iiwce 'D-Ioq Ve^* WOShl► q d TAP <br /> REET CITY FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> �--ele�tpn ✓� 2243- 2oto32 i�' 1 (�� �3`�I-3 <br /> U ADDRi<SS Z� DOLV iv�i Dave. 5t�xf'Dr� 5oa <br /> O 4l/D ti <br /> UJ STFlEET CfTY COUNTY Zlp <br /> N <br /> CROSS STREET <br /> SSWSJ . <br /> 1" � <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> zN <br /> Zw <br /> Lu� u)n �. �n�. ect 4a-cLw khd l (2* 4693y y z <br /> w REGIONAL BOARD PHONE <br /> a. Cen- I Vatle RWQCg �"1tu�. 11^71 ems►-- R(o ) 255-3133 <br /> y (i) NAME QUANTITY LOST(GALLONS) <br /> W> � 5ollh� <br /> J UNKNOWN <br /> In z (2) <br /> N ❑ UNKNOWN <br /> F DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL F7SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> z /� <br /> w �M� ^MI I D v �r ❑ TANK TEST ❑ TANK REMOVAL (y OTHER t4Aj(tans s1Y1�►ti�'" <br /> a <br /> CD GATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> �l1NKNOWN E]REMOVE CONTENTS ❑CLOSE TANK E REMOVE ❑REPAIR PIPING <br /> W M D Y <br /> 0 HAS DISCHARGE BEEN STOPPED Z ❑REPAIR TANK ❑CLOSE TANK E FILL IN PLACE ❑CHANGE PROCEDURE <br /> o ❑ YES � NO IF YES.DATE MI .1 v Y ❑REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> a ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPIIL <br /> c v ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ 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 ONE ONLY <br /> z NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> cc <br /> LEAK BEING CONFIRMED ❑ PRELIMINARY SITE 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&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> Q <br /> (SEE FOR DMARS) <br /> Z <br /> o O ❑ CAP SITE(CD) ❑ EXCAVATE d TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> Lu a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> cr <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> �, Soil qnd 91pundwaic l W45 LndacawA O✓1 P� ObSe+'�a t1o✓15 <br /> z b- soil a lA oraJ✓Owad� llZS Col(¢c kcl L L)V%� uj a,�=f 4vui-Lt t6v� Q�Se55rvt2vi�, <br /> fvr�er �tQ q$Sesswic, t Wal bQ- r Otred -� de-de -2 J'kj tOUVCZ + e-,A�r <br /> o��l.e, 501 q v� ravnd�w4dQ-+ coAiremuv bo✓) p,5 requtrtj re ukfv <br /> HSC OLAW <br />