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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVI S FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED? 1 HEREBY CERTIFY THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT 1 HAVE <br /> YES NO YES REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTIO 25180.7 OF <br /> REPORT DATE CASE s THE H AND SAFTY COO `, <br /> r /j/S! y Z <br /> 0 MI / Mi /d S r�2 vI SIGN DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> 0 REPRESENTING ❑ OWNEFLOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> OCAL AGENCY ❑ OTHER S U/l <br /> a <br /> 2 ADDRESS <br /> (.' ♦'�e D ST-EET > CTTr STATE 21P' <br /> NAMEEJ CONST PERSON -�/nI PHONE c �] <br /> (\/u..UW'C�4�' C•-f�•l Fi�J� ❑ UNKNOWN �+�� �+t��.�'�Cil� (f J)) <br /> a <br /> (L ADDRESS CA <br /> gT <br /> E_ STATE ztp <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ADDRESS �- <br /> b Lv. 1,�✓ rte' <br /> Sa---J rte <br /> T CITY cou . a <br /> y CROSS STREET TYPE OF AREA COMMERCIAL a INDUSTRIAL❑RURALTYPE OF BUSINESS X q TAIL FUEL STATION <br /> RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> w GIONAL BOAR . PHONE <br /> (I) NAME QUANTITY LOST(GALLONS) <br /> to <br /> W <br /> UNKNOWN <br /> CD <br /> � <br /> ❑ UNKNOWN <br /> DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> 2 v M J M o r r ❑ TANK TEST TANK REMOVAL OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> L" M M o o Y <br /> UNKNOWN <br /> r <br /> ❑ REMOVE CONTENTS ❑ REPLACE TANKcc CLOSE TANK <br /> D� HAS DISCHARGE BEEN STOPPED? ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> p YES ❑ NO IF YES.DATE .1 Mi o� DI rj r ❑ OTHER <br /> u� SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK UNKNOWN ��bC� 121400 GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURE FAILURE <br /> ❑ PIPING LEAK AGE -Z-5- YRS STEEL ❑ CORROSION �NKNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w CHECK ONE ONLY <br /> ❑ UNDETERMINED ❑ SOIL ONLY Vr"GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> z CH;FE ONLYz�irITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) a CLEANUP IN PROGRESScc <br /> ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> U w ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTIONS)(SEE BACK FOR DETAILS) <br /> b ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED 010 DEGRADATION(IT) <br /> LU <br /> ❑ CONTAINMENT BARRIER(CB) �CAVATE d TREAT(ET) ❑ PUMP 8 TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> O TREATMENT AT HOOKUP(HU) O NO ACTION REQUIRED(NA) O OTHER(OT) <br /> HSC 05I�an <br />