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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 4 I HEREBY CERTIEYTHAT L NAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> 0 YES NO YES NO <br /> INSTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF_THIS FORM. <br /> REPORT DATE CASE x <br /> M M SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> m �-o/ (&79,)el(oJ `?Y'60 <br /> w REPRESE G 0 OWNER/OPERATOR 0 REGIONAL BOARD COMPANY OR AGENCY NAME <br /> cc LOCAL AGENCY OTHER j <br /> 0 Ef 4J -�.1 ddjl" <br /> cc <br /> ADDRESS <br /> -"[ Cmc'o' EE� (/ Gf®0'°) CITr STATE <br /> ZIP <br /> w NAME CONTACTPERSON PHONE <br /> Z¢ GaP �o d UNKNOWN Al <br /> d <br /> O< ADDRESS <br /> to <br /> tr <br /> STREET CITY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> / <br /> ADDRESS ��°qq c _ <br /> I jQ /(.P �P e REEF C� <br /> CITY COUNTY ZIP <br /> y CROSS STREET <br /> J Zoe_ <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> zw <br /> z <br /> w `0 Vin_ <br /> w Ci REGIONAL BOARD /PHONE <br /> < co (7) NAME QUANTITY LOST(GALLONS) <br /> wp <br /> GJ �/.. UNKNOWN <br /> m> (z) <br /> N Z <br /> UNKNOWN <br /> z DATE DISCOVERED HO�TA VERED ❑ INVENTORY CONTROL SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> w M) M o v Lu <br /> NK TEST � TANK REMOVAL OTHER t <br /> m DATE DISCHARGE BEGAN METHOD UWO TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> w <br /> .1 DI Yl v <br /> UNKNOWN REMOVE CONTENTS D CLOSE TANK&REMOVE REPAIR PIPING <br /> p HAS DISCHARGE BEEN STOPPED 7 F REPAIR TANK Q CLOSE TANK&FILL IN PLACE CHANGE PROCEDURE <br /> S2 YES [::] NO IF YES,DATE MI MI D11I Yl Y 0 REPLACE TANK OTHER <br /> 0 SOURCE OF DISCHARGE CAUSE(S) <br /> w <br /> U) <br /> TANK LEAK UNKNOWN F OVERFILL Q RUPTURE/FAILURE SPILL <br /> N o Q PIPING LEAK F-] OTHER Q CORROSION 0 UNKNOWN OTHER <br /> Lu Lu CHECK qW16NLY <br /> U UNDETERMINED 0 SOIL ONLY ❑ GROUNDWATER [—] DRINKING WATER-(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> Iz F--] NO ACTION TAKEN F-1PRELIMINARYSITE ASSESSMENT WORKPLAN SUBMITTED Q POLLUTION CHARACTERIZATION <br /> Er ❑ LEAK BEING CONFIRMED F-� PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> O F-1 REMEDIATION PLAN F-� 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 /> J (BEE BACK FM WTMA) <br /> `-=z CAP SITE(CD) EXCAVATE 8 TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)Q REPLACE SUPPLY(RS) <br /> p O <br /> Lu F.- <br /> � CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) Q TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> VACUUM EXTRACT(VE) F-1 OTHER(OT) <br /> o <br /> z <br /> . HSC 05(SIM <br />