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FILE <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 FILED v �`� .I HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> .17 YES x NO 1701 YES ❑ NO <br /> �YY���'""" J///``����-''���` DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE Of THIS FORM, <br /> REPORT DATE /%,' CASE s <br /> r 613.1 0� 1 o v 1 9 v SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> o REPR SENTING COMPANY OR AGENCY NAME <br /> w ❑ OWNERiOPE TOR ❑ REGIONAL BOARD <br /> O LOCAL AGENCY OTHER <br /> w <br />_ s ADDRESS <br /> J o F- , 7,::2d 0� <br /> STREET CRY STATE ZIP <br /> w NAME CONTACTPERSON PHONE <br /> zD ` G S ❑ UNKNOWN f,ZOq) T��j J�CJ <br /> Q <br /> d a ADDRESS ?5;D <br /> N -oo Nle,U) -ov P�,Bax S4-o�.��� l £3 <br /> w <br /> STREET CRY STATE zip <br /> FACILITY NAME(IF APPLICABLE) OPERATORPHONE <br /> FR 4W K <br /> a ADDRESS <br /> Lu STREET CRY COUNTY ZIP <br /> CROSS STREET <br /> C7 LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> w S, . C°v <br /> w REGIONAL BOARD PHONE <br /> N (1) AME QUANTITYLOST(GALL <br /> 0 Lu <br /> �3�n �c.rvc, 'iolwG/V� �17j Xyfeytcs , TPS, A�T$1L�Ti�.��� ar10 UNKNOWN <br /> `a Ccs G Cyo <br /> o (2) <br /> UNKNOWN <br /> DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> ui <br /> z <br /> w OrA 3�i �oI e.1 v I v ❑ TANK TEST TANK REMOVAL OTHER <br /> m57 <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> T UNKNOWN MOVE CONTENTS LOSE TANK&REMOVE ❑REPAIR PIPING <br /> `= <br /> w M DI r <br /> HAS DISCHARGE BEEN STOPPED 9 ❑REPAIR TANK ❑CLOSE TANK S FILL IN PLACE ❑CHANGE PROCEDURE <br /> YES ❑ NO IF YES.DATE vMl / 1 0� oI r� r ❑REPLACE TANK ❑ OTHER <br /> w SOURCE OF DISCHARGE CAUSE(S) <br /> cr <br /> a F7TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> w w 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 /> W <br /> `F <br /> NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> CC c ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U � <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPPROPRRIIATE A TIONS) EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) j ENHANCED BIO DEGRADATION(IT) <br /> (SEE�Zgj ❑ DEIMS1 Ix <br /> CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) I PUMP&TREAT GROUNDWATER(GT)= REPLACE SUPPLY(RS) <br /> w� <br /> L ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> j❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> L <br /> HSC m1&-m <br />