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r <br /> r <br /> r_.. <br /> I� <br /> SPILL/LEAK REPORTING FORM Rev. 8 2/64.1 <br /> TO: Toxics Cleanup Division <br /> RWOCB, Re. 6040 <br /> 1111 Jackson St. <br /> Oakland, CA 94607 FERMII/SERVICLS <br /> Report Date:_O _/Z�D _1 � Reported By:_ G_ ---__ <br /> Facility Facility <br /> Name:---- Cf los------- Address:-4a 42?" <br /> Facility <br /> Contact _&4q:o-V e-s ___-- Phone: _- _ <br /> /¢N/V�fBEZ SNE -Su;nir 2-oa <br /> Owner: '14��/�Qnl u_$ 14NG__ Address: .3AN JpPr4r+'1o11 FC' !�f3 <br /> Contact:j4_j fTDN/_�L)f�JIQQ Phone: ( �/�) G•3�� <br /> Date Discovered:_ a /�0_/ Date Started:__/____- <br /> How Tank �� Routine �f� <br /> Detected: Removal Monitoring___- Other �- <br /> Chemicals: �AS 6 LlIJ Max. Concentration: <br /> --------------------- ------------ <br /> w <br /> Est.Vol.Lost: Est.Method:__ r� _/ <br /> Tank Ager , Tank, Volume'. /O 604) Tank Material :_�T _ <br /> Pressure Test: Tank_____ -Piping----- Leak Stopped:_ <br /> Contamination Defined: Soil__________ Floating Product_________ <br /> Local Wells Sampled <br /> Monitoring Well Data:_____ Product Plume Cleanup:=_________ <br /> Vapor Check (Y/N) :____ Results: Storm Drains____ Sewers___-_ <br /> Utility Vaults_____ Bldgs____,__ <br /> f Other---------------- -------- ------ <br /> Other Agencies Notified: ,-5 _ <br /> -------------------------------- -------- <br /> Status and Proposed Activities*._4- <br />