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7. <br /> Ro�u4 <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 FLED 7 1 HE*BY.CERTIFYIHAT LAM.A Of S10NAtE0�aOYEEiNMENf,EMpGOYEE ANb fiNAT I HAVE; <br /> ❑ YES ®'ND ❑YES Zr No <br /> REPORTEDTHIg INFORMATION TO LOCA- DFFIC PURSUANT TO SECTION 26160 'OF, <br /> REPORT DATE CASE* THEN ANDSAFTYCODE, <br /> q , <br /> SIGNED. i DATE <br /> NAMEOF INDIVIDUAL FLING 4 PHONE� f � SIGNATURE <br /> o REPRESENTING ❑ OW/NEWOPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME <br /> O LOCAL AGENCY ❑ OTHER �4n S I 'o al <br /> A <br /> ADDRESS n� x o/ <br /> o / yzz-/ .-� frac ��'► <br /> STREET SCRY STATE 21P <br /> NAME CONTACT PERSON PHONE <br /> La �� o LIN Grr ' I koo o � (y�s) 76- yi y <br /> z <br /> Ra ADDRESS <br /> ro <br /> % (o [�/ IIS r w CITY STATE ZIP <br /> FACILITY NAM!E(IF APPLICABLE) OPERATOR/ PHONE <br /> v c -4e� <br /> ADDRESS / ,OfQ�. SA�' 95, Z-4b <br /> 4JZU w STRcrC'M,a7 C <br /> STREETT CITY COUNTY ZIP <br /> yCROSS STREET TYPE OF AREA ❑COMMERCIAL❑INDUSTRUIL❑RURAL TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> ❑RESIDENTIAL [-]OTHER ❑ FARM ❑ OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON ' PHONE <br /> g2 SQ"7 jof ,.4�1 Co. <br /> M <br /> Lu REGIONAL ARD PHONE <br /> (�) NAME QUANTITY LOST(GALLONS) <br /> w <br /> u <br /> UNKNOWN <br /> (Z) f <br /> `�T �O VC�7 t ❑ UNKNOWN <br /> DATEDISCOVERED HOWDISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACEMONITORING NUISANCECONDITIONS <br /> M M l� o y r ❑ TANK TEST ❑ TANK REMOVAL OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY)v <br /> UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> w M M D 0 Y Y <br /> HAS❑DISC�DISCHARGE BEENtOPPES SATE M M D D r r ❑ SER TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> u� SOURCE OF DISCHARGE TANKS ONLYrcAPACITY MATERIAL CAUSE(S) <br /> 4 ❑ TANK LEAK UNKNOWN GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE <br /> �¢' ❑ PIPING LEAK AGE YRS ❑ STEEL ❑ CORROSION ❑ UNKNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w CHECKONEONLY <br /> Il <br /> 01"UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ON=ONLY <br /> cr <br /> Q SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANCA�N ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVG AN =T <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 4z ❑ CAP SITE(CD) ❑ EXCAVATE Q DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> M ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE 6TREAT(ET) EJPUMPbTREATGROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑j—TREATMENT ATi-IOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(07) LL <br /> y /—vr f�� S+� d/J y>~•5l�f4 ' rJ !yi' �Q c'I 74' G2�CTci�rli�lc f�f <br /> ex�� <br /> 8 /:e �, �y �f��y fro f, C. (�,, <br />