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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 FILED 7 <br /> F—] YES i�No ❑ YES [Q NO 1 HEREBY CERTIFY THAT 1.HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OFTHIS FORM. <br /> REPORT DATE CASE s <br /> O / M / / v SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONESIGNATURE <br /> m (3-TV) d' --� <br /> REPRESENTING ❑ COMPANY OR AGENCY NAME <br /> OWNER/OPERATOR REGIONAL BOARD <br /> ❑ LOCALAGENCY ❑ OTH�E/R' / /fxro <br /> ¢ ADDRESS f'✓��/` (G L� L Cof <br /> STREET CITY STATE ZIP <br /> W NAME /f,,�'�, -+ ,r� CONTnACT PERSON Com,,,' /� PHONE (�, '] <br /> co �J/c�(ilJ /C.C7�'L UNKNOWN C/ Z�1/� '�1, /'CEJ ( ) ! D/ <br /> a ADDRESS <br /> STREET CITY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> O Pia <br /> U ADDRESS (j�— L� l E <br /> rox <br /> W STREET CITY COUNTY <br /> ZIP <br /> CROSS STREET <br /> 1 <br /> z LOCAL AGENCY AGENCY NAME CONTACT PERSON d901414- l�1L��G/ PHONE <br /> rn � A <br /> �w <br /> w <br /> > uIN �ocs�'- Hgv1y Dlli�• G4�2l€- H�iu� may) 3-1A <br /> U <br /> w w REGIONAL BOARD PHONE <br /> J(7 <br /> y (t) NAME QUANTITY LOST(GALLONS) <br /> 00 <br /> W t4/Vc�/lGo� �Lf/� i�/�L [:] UNKNOWN <br /> Z <br /> Q J <br /> In H <br /> m o (2) <br /> U) ❑ <br /> UNKNOWN <br /> z <br /> DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING 0 NUISANCE CONDITIONS <br /> Luul <br /> bD v1 3 v ❑ TANK TEST ❑ TANK REMOVAL OTHER <br /> CD <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a_ y <br /> } M M D D �v v D UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE E]REPAIR PIPING <br /> w <br /> p HAS DISCHARGE BEEN STOPPED 9 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑:]CHANGE PROCEDURE <br /> o ❑ YES ❑ NO IF YES,DATE <br /> M MI D D V Y ❑REPLACE TANK OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL Dom--99' <br /> U)U ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN OTHER <br /> L" 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 ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED 0 POLLUTION CHARACTERIZATION <br /> D¢ <br /> N ❑ LEAK BEING CONFIRMED F-1PRELIMINARY SITE ASSESSMENT UNDERWAY E:] POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN EZ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE,ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED 810 DEGRADATION(IT) <br /> J ISEE BACK FOR DETAIS) <br /> Z CAP SITE(CD) EXCAVATE&TREAT E PUMP&TREAT GROUNDWATER G <br /> w O ❑ ❑ ( T) ❑ ( T)❑ REPLACE SUPPLY(RS) <br /> w a ❑ CONTAINMENT BARRIER(CB) E:] NO ACTION REOUI RED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> �❑ VACUUM EXTRACT(VE) © OTHER(OT) G��'NI� CQr/ �p �s7Vr H '�fj}� *rP f— 6 F/ P17E— <br /> n <br /> t <br /> z c a <br /> w <br /> o <br /> U <br /> �1 <br />