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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> F-1 YES NO REPORT BEEN FILED 7 <br /> ❑ YES ❑ NO 1 HEREBY CERTIFYTHAT I.HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT DATE (� CASE i <br /> VM -I -\ D 2-y SIGNED <br /> DATE <br /> NA E OF INDIVIOU FILING REP R PHONE SIG`RE . <br /> � VC4 <br /> Lu REPRE ENTING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD <br /> ANY OR AGENCY NAME <br /> gLOCAL AGENCY ❑ OTHER <br /> w v 1 <br /> cc <br /> ADDRESS <br /> CTI STATE ZIP <br /> J NAME CONTACT PERSON PHONE <br /> m <br /> Z Q ❑ UNKNOWN ) <br /> OCL a ADDRESS <br /> Lu <br /> STREET crry STATE ZIP <br /> 7 <br /> PHONE <br /> FACILITY NAME(IF APPLICABLE) OPERATOR <br /> O ) <br /> ADDRESS <br /> rv' �1 ray^ (M��i�J� C G <br /> O l V `'` STREET iA rJ�� �� Ck 1 5(3 <br /> ~ <br /> N CROSS STREET cAurrrr ZIP <br /> Z LOCAL AGENCY AGENCY NAME CONTACT PERSON <br /> PHONE <br /> P �` bre � ) <br /> w L REGIONAL BOAR PHONE <br /> as <br /> LU (�) NAME QUANTITY LOST(GALLONS) <br /> U Ow 1 <br /> SLS S ❑ UNKNOWN <br /> CO z (2) <br /> w <br /> ❑ UNKNOWN <br /> r DATE DISCOVERED HOW DISCOVERED <br /> z ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Lu <br /> ` .10fl/` <br /> w v M� '6 Ml , o1 r� r E] TANK TEST �7 TANK REMOVAL ❑ OTHER <br /> aDATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M o o r r UNKNOWN ❑REMOVE CONTENTS LOSE TANK d REMOVE ❑REPAIR PIPING <br /> 10 <br /> p HAS DISCHARGE BEEN STOPPED 9 ❑REPAIR TANK CLOSE TANK d FILL IN PLACE ❑CHANGE PROCEDURE <br /> o YES ❑ NO IF YES,OATS 6.15 j 113 .1 <br /> j 6y 2-v ❑REPLACE TANK ❑ OTHER 1 <br /> LDw <br /> S RCE OF DISCHARGE CAUSE(S) O <br /> 1 ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> On O ❑ PIPING LEAK OTHER ❑ CORROSION r7�41NKNOWN Q OTHER <br /> w 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 /> cn <br /> w ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br /> n: <br /> x N LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY E::] POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE d DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> J (SFE BALK FOR DEE A <br /> a z CAP SITEXCAVATE 8 TREAT <br /> o O ❑ (CO)( ) ❑ (ET) ❑ PUMP d TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> w a CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> Q ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> W <br /> z <br /> z <br /> w <br /> o� <br /> U <br /> HSC 0.5(&90) <br />