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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 /> REPORT BEEN FILEDNO I HEREBY CERTIFY THAT 1 HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> F-1 YES NO � YES <br /> DISTRIBUTION SHOWN ON T I <br /> (E�P�ORT NSTR CTION SHEET ON THE BACK PAGE OF THIS FORM <br /> RDATE CASE i �--� G <br /> "'M (9 <br /> MI l SIGNED -7 DA E <br /> NAME OF INDIVIDUAL FILING REPORT PHONE NATURE <br /> n a/ Kl �. Cwq)y b 9-o33 <br /> co <br /> ww REPRESEN NG ❑ OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> crLOCALAGENCY [:] OTHER J C <br /> ¢ [ADDRESS[/�' j( ^ <br /> I /V / T QT L��1 {,J _ 1 ` STATE Y, ZIP <br /> w NAME CONTACT PERSON PHONE <br /> 03 <br /> J (�y <br /> z � UNKNOWN ��r ✓ Cih <br /> O a ADDRESS <br /> En <br /> /'7 ( � �E1�-�� CITY N ` STATE <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> Arc v 417 ( ) <br /> UADDRESS -� <br /> q / 4 ` /� <br /> L I l T1 L'_ cm N,, C� COUNTY <br /> ` �SZIP <br /> w <br /> ~ <br /> Fn STREET <br /> 1-k z Y� <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> w w REGIONAL BOAAD PHONE <br /> CV 1W j5 <br /> ``oo Jnnr1 NAME QUANTITY LOST(GALLONS) <br /> a w �� ❑ UNKNOWN <br /> m z (z) <br /> ❑ UNKNOWN <br /> Z DATE DISCOVE^REED a HOW DISCOVERED ❑ <br /> INVENTORY CONTROL ❑ SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> w MI 2MI `- %1 (Y ❑ TANK TEST [:] TANK REMOVAL ❑ OTHER <br /> a <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) l <br /> 3-1 NKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE 4YOPAIR PIPING <br /> Cc M M D D Y Y <br /> O HAS DISCHARGE BEEN STOPPED 7 O REPAIR TANK ❑CLOSE TANK&FALL IN PLACE]❑CHANGE PROCEDURE <br /> o YES ❑ NO IF YES,DATE -I Y v ❑REPLACE TANK 'OTHERal <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> w <br /> ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL RUPTURE/FAILURE ❑ SPILL <br /> U)O ❑ PIPING LEAK OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> Lu w CHECK ONE ON <br /> U)a <br /> v UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> w <br /> P ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(IT) <br /> Q Z (SEE BACK i IXTAIS) <br /> ❑ CAP SITE(CD) ❑ EXC ATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w< ❑ CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> c ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> ui <br /> HSC 05(891) <br />