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.. 0zz <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES :FOR LOCAL'AGENCY USE ONLY <br /> ❑ YES ❑ NO REPORT BEEN FILED 7 (YES ❑ NO 1 HEREBY CERTIFYTHAT 1 HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> L� DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM. <br /> REPORT DATE Q� CASE a <br /> M Z MI lJ r SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> ` Lp- (m) ) 6FS- eig(Ica <br /> w REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> gLOCAL AGENCY ❑ OTHER Sam <br /> Q ADDRESS f�dCp/��/ 7�\`1-�'�7� //;; <br /> VREET J C STATE ZIP <br /> w NAME CONTACT ERSON PHONE <br /> m 4 <br /> z 1 ❑ UNKNOWN (��y) <br /> acn a ADDRESS r <br /> w <br /> cr <br /> 91 q STREETc'C STATE <br /> FACILITY 14AME(IF APPLICABLE) OPERATOR PHONE <br /> o � <br /> Aiavz-(tl-- 7 let q - 3rd <br /> a AD SS <br /> � ZIP <br /> m CROSS STREET <br /> Y.� <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> z <br /> ~w ( ) <br /> w U <br /> w w REGIONAL BOARD PHONE <br /> J <br /> CL a <br /> w (1) ` NAME QUANTITY LOST(GALLONS) <br /> C <br /> a> ( ❑ UNKNOWN <br /> CDz (2) <br /> � <br /> ❑ UNKNOWN <br /> Z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> w MI � �� 1 D a rI 3r ❑ TANK TEST ❑ TANK REMOVAL OTHER 4.; <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> cr 1A D D r r UNKNOWN ❑REMOVE CONTENTS CLOSE TANK a REMOVE ❑REPAIR PIPING <br /> p HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK CLOSE TANK a FILL IN PLACE E:]CHANGE PROCEDURE <br /> U <br /> cn <br /> YES ❑ NO IF YES,DATEM A9 II D V Y ❑REPLACE TANK ❑ OTHER <br /> � <br /> S URCE OF DISCHAR CAUSE(S) <br /> cc UNKNOWN ❑ OVERFILL ❑ RUPTURFJFAILURE ❑ SPILL <br /> U ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> Uw wa 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 Z ❑ NO ACTION TAKEN ❑. PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> w <br /> tz <br /> ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U y <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE a DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED 1310 DEGRADATION(IT) <br /> J (SL£BACK FOR DETAIS) <br /> sc ZElCAP SITE(CD) ❑ EXCAVATE a TREAT(ET) E::] PUMP a TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w� <br /> w< ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> x <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> r <br /> z <br /> w <br /> � ) J VVV III <br /> HSC 05(8/90) <br />