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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br /> REPORT BEEN FILED 7 FOR LOCAL AGENCY USE ONLY . <br /> YES NOES [] NO I HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> RPOR`T�OATET� r DISTRIBUTION SHOWN ON THE.NSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> +� J CASE s r <br /> DATE <br /> NAME OF INDIVIDUAL FILING REPORT_ _ PHONE SIGNATURE <br /> m <br /> w REPRESENTING ❑ OWNERVOPERATOR F7REGIONAL BOARD COMPANY OR AGENCY NAME <br /> cc LOCALAGENCY ❑ OTHER <br /> Q ADDRESS <br /> tzg, <br /> STREET CRY STATE ZIP <br /> J NAME CAMNTACTPERSON /PHONEE y <br /> Z ❑ UNKNOWN <br /> 2 <br /> Oa d ADDRESS <br /> to <br /> U) <br /> X <br /> STREET Cllr STATE p <br /> FACILITY NAME(IF APPLICABLE) OPERATOR r PHONE <br /> onA a r e-S C O p/ttA l iG�/rCGr.a /� (�0 , IT3 7e <br /> a ADDRESS <br /> CITY <br /> COUNTY ZIP <br /> r—n CROSS STREET <br /> m Stl, <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> w w REGIONAL BOARU <br /> //' <br /> PHONE <br /> CL <br /> a <br /> a W L/. <br /> E <br /> LU AME QUANTITY LOST(GALLONS) <br /> o J (• <br /> U LU <br /> Z J "r , lg Slf/� UNKNOWN <br /> ca_ (�) <br /> `" ❑ UNKNOWN <br /> N- DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Lu <br /> zI �j <br /> Z / u� f � ✓o1 `rI r [:] TANK TEST TANK REMOVAL ❑ OTHER <br /> I- <br /> a DATE DISCHARGE BEGAN <br /> m METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> OUNKNOWN REMOVE CONTENTS 1>Q CLOSE TANK 6 REMOVE ❑REPAIR PIPING <br /> �>� HAS DISCHARGE BEEN STOPPED? REPAIR TANK ❑CLOSE TANK 3 FILL IN PLACE ❑CHANGE PROCEDURE <br /> O—' <br /> YES [1] NO IF YES.OATS l uI r J o �oI v r ❑REPLACE TANK ❑OTHER <br /> 0 <br /> Lu <br /> SOURCE OF OISCHARGE CAUSE(S) <br /> i TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTURElFAILURE ❑ SPELL <br /> U ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> u+w CHECK ONE ONLY <br /> ma <br /> U ❑ UNDETERMINED % SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY _(1 <br /> zNO ACTION TAKEN F7 PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED C:] POLLUTION CHARACTERIZATION �t <br /> W cc -1Z <br /> w <br /> j N LEAK BEING CONFIRMED F7PRELIMENARY SITE ASSESSMENT UNDERWAY 0 POST CLEANUP MONFTORING IN PROGRESS <br /> U REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE G DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> =e.uc raw DUALM <br /> a z ❑ <br /> oO CAP SITE(CD) ❑ EXCAVATE d TREAT(ET) ❑ PUMP 3 TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> a ❑ CONTAINMENT BARRIER(CB) 0 NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) -�VENT SOIL(VS) C <br /> ❑ VACUUM EXTRACT(VE) 1❑ OTHER(OT)ui <br /> " SCG C�CJ� <br /> U <br /> cyt <br /> Mae OS(BND) <br />