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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 T <br /> YES NO ❑ YES ❑ NO I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> REPORTED THIS INFORMATION TO LOC OFFICIALS PURSUANT TO SECTION 25180.7 Of <br /> REPORT DATE CASE* THE HEALTH AND SAFTY CODE <br /> DM �Y D Y WNW <br /> NAME ANUIVIIJUAL FILING REPORT DATE <br /> PHONE SIGNATURE <br /> REPRESENTING ❑ OWNER/OPERATOR REGI L BOARD MPANY OR AGENCY NAME <br /> LOCAL AGENCY ❑ OTHER <br /> cr { bI1G ' <br /> ¢ ADDRESS <br /> CITU I 21P <br /> NAME CONTACT PERSON �APHONE <br /> T <br /> Z QUNKNOWN S � / p <br /> gas ADDRESS I L/� /-- <br /> Ty <br /> 3T � 6 <br /> FACILITY NAME(IF APPLICABLE) OPERATOR AT9 ) <br /> PHONE <br /> ADDRESS <br /> y CROSS STREET CRY COUNTY ZIP <br /> TYPE OF ARA ❑COMMERCIAL ❑ INDUSTRIAL RURAL TYPE OF BUSINI <br /> "� ❑ SS ❑ RETAIL FUEL STATION <br /> /v F, F-o q o O RESIDENTIAL <br /> OTHER 7 FARM OTHER <br /> AL AGENCY AGENCY NAME W W71 CONTACT PERSON <br /> PHONE <br /> w REGIONAL BOARD <br /> CL aPHO <br /> V NE <br /> !�V G z3c9 <br /> UQUANTITY <br /> NAME `/ LOST(GALLONS <br /> N 0 � CiO N5 NKNOWN <br /> (2 j <br /> N <br /> ❑ UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED <br /> w R INVENTORY CONTROL SUBSURFACE MONITORING � NUISANCE CONDITIONS <br /> M �D _D r TANK TEST ❑ TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> i <br /> w M M D D r y UNKNEl <br /> OWN REMOVE CONTENTS a REPLACE TANK a CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED? ❑ REPAIR TANK O REPAIR PIPING ❑ CHANGE PROCEDURE <br /> o O YES O NO IF YES,DATE ❑ OTHER <br /> M M D D r y <br /> rw SOURCE OF DISCHARGE TANKS ONLYC PA ITV MATERIAL <br /> CAUSES) <br /> ❑ TANK LEAK UNKNOWN __ /Oo GAL. a FIBERGLASS a OVERFILL ❑ RUPTURE/FAILURE <br /> El PIPING cc <br /> LEAK AGE � <br /> 0 [:] UNKNL OL YRS ❑WN OTHER ❑ CORROSION ❑ UNKNOWN <br /> OTHER <br /> w� SPILL OTHER <br /> CHECK ONE ONLY <br /> ❑ <br /> ❑ UNDETERMINED SOIL ONLY GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK O ONLY <br /> ¢ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> ¢F <br /> U f° ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 80 ❑ CAP SITE(CD) <br /> El EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> ❑ CONTAINMENT BARRIER(CB) a EXCAVATE&TREAT(ET) ❑ PUMP d TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) 1 <br /> TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) C <br /> U) 54,0;L res�r S re V cit 1 CDi✓Ti�h-1 / <br /> �'A" -"X," k- <br /> ,57 5 e 5s✓Nzv,f w:LL e— re :i2 �, l <br /> 7�il.,r <br /> r c Piste c <br /> �u�en <br />