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(�lJ02-2 <br /> 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 <br /> ❑ YES NO YES NO <br /> I HEREBY CERTIFYTHAT i HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> ❑ <br /> DISTRIBU ONSHOVINONTHEINS UCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> (REPORT <br /> DATE CASE <br /> 7 Y SG N DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> L fca ' � �-- I3 r )` S c�c�) 6��3 e <br /> LOU REPRESENTING ❑ OWNER/OPERA7 ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> x LOCAL AGENCY ❑ OTHER `Swcc <br /> ADDRESS r L� PTE• 1 S I /W7G� iC S�©C � ��� <br /> 33 J- STREET CT STATE ZIP <br /> Lu NAME �,��,^ CONTACT PERSON (PHONEco <br /> ,y <br /> z" csh ► V►1, UNKNOWN <br /> o: <br /> Qa ADDR S <br /> D r0 J ', Q cit�►- �'• S 1 v <br /> STREET CITY STATE Ip <br /> FACILITY NAME(IF APPLICABLE) OPERATORPHONE <br /> z - r S (,�- 17 .5 ( ; aD i �S� -y� r <br /> 0 <br /> ADDRESS srR � <br /> o / (/aEr ��IP <br /> W <br /> CITY COUNTY ZIP <br /> CROSS STREET <br /> w e S f -Q/►'�y <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> w , C m W- 1/4(?-34.6 <br /> w w REGIONAL BOARD PHONE <br /> J< <br /> LJ (1) .e;y� , NAME T 9 / QUANTITY LOST(GALLONS) <br /> Z w PrUNKNOWN <br /> Q J <br /> cn <br /> m> (2) <br /> U) ❑ UNKNOWN <br /> DATE DIS1lCOVE�R}ED L/'� —17 HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Al f Mi ✓ D D1 `Yl 1r ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> Q �NKNOWN REMOVE CONTENTS LOSE TANK&REMOVE REPAIR PIPING <br /> w M M D D Y Y <br /> 0 HAS DISCHARGE BEEN STOPPED Z E:]REPAIR TANK CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> o <br /> E] YES ❑ NO IF YES,DATE LSM I MI JD o YJ <br /> �Y ❑REPLACE TANK ❑ OTHER <br /> q SOURCE OF DISCHARGE CAUSE(S) <br /> w <br /> j F7TANK LEAK UNKNOWN OVERFILL RUPTURE/FAILURE SPILL <br /> O PIPING LEAK ❑ OTHER CORROSION UNKNOWN ❑ OTHER <br /> Lu w CHECK ONE ONLY <br /> O ❑ 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 /> Ly X11 <br /> fL <br /> c ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> v ❑ 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 /> J (SEE BACK FOR MTMSI <br /> aZ <br /> 00 F-1CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) F7PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> Lu a CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> Q <br /> VACUUM EXTRACT(VE) OTHER(OT) <br /> ui <br /> o <br /> HSC 05(MO) <br />