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AIL i q5 03y <br />UNDERGROUND STORAGE TANK UNAUTHORIZ F[ELEASE (LEAK) / C JTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />❑ YES ® NO REPORT BEEN FILED? 1_j YES ® NO <br />FdR tOCAt'AGENCY <br />HEFM CEATIFYTHAT V I1 tBl ]HJTHIS INFORMATION ACCORDING TO THE <br />BUTION ON�TF SHEET ON THE BACK PAGE OFTH(S FORM ' <br />i wl {tF F r <br />REPOR//T''DATE 7CASEB <br />j3U NNiUM <br />p(i- OS (.+ IJJo <br />l <br />.iliallED DATE <br />NAME OF INDIVIDUAL FILING REPORT <br />PHONE <br />SIGNATURE <br />REPRESENTING OWNERIOPERA ❑ REGIONAL BOARD <br />COMPANY OR AGENCY NAME <br />S <br />❑ LOCAL AGENCY ❑ OTHER <br />aRCA R ro I Cc <br />ADDRESS 0 2_ <br />STREET My R S SCA STATE <br />Lu <br />NAME <br />CONTACT PERSON <br />i <br />�CC O (O Co ❑ UNKNOWN <br />J <br />/PHONE <br />( ) <br />so;R <br />ADDRESS <br />Lu <br />Q <br />STREET CRY STATE Zvp <br />FACILITY NAME (IF APPLICABLE <br />OPERATOR <br />PHONE <br />o <br />ar�c� 7c,0. S45G__ <br />U <br />ADDRESS <br />RS Z 3> <br />l <br />1 <br />w <br />j <br />t D \ STREET liV e YU` ( Cm' ZIP <br />~ <br />m <br />CROSS STREET <br />- 5 TN � <br />p <br />LOCAL AGENCY AGENCY NAME <br />CONTACT PERSON <br />PHONE <br />z — <br />�w <br />w U <br />S �vp, u I� Cp E 4� <br />\.ce-� <br />M.A <br />w w <br />REGIONAL BOARD <br />PHONE <br />12 <br />/ <br />w <br />(1) NAME OUANTTTY LOST (GALLONS) <br />LU <br />�D AS �` ® UNKNOWN <br />mz <br />m <br />W <br />❑ UNKNOWN <br />i <br />DATEDISCOVEREDDISCOVERED <br />HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING 0+ NUISANCE CONDITIONS <br />1 <br />1, M � M O o Ct r <br />❑ TANK TEST ❑ TANK REMOVAL ® OTHER fro u L t 5Z \G Ce vy, u rt <br />m <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />wu <br />UNKNOWN <br />❑ REMOVE CONTENTS ❑ CLOSE TANK 8 REMOVE ❑ REPAIR PIPING <br />❑ REPAIR TANK ❑ CLOSE TANK & FILL IN PLACE ❑ CHANGE PROCEDURE <br />HAS DISCHARGE BEEN STOPPED 7 V NK NU W <br />o <br />YES ❑ NO IF YES. DATE <br />4 <br />❑ REPLACE TANK M OTHER 1;4 vn G 1V ro Lm) - U <br />w o r r <br />SOURCE OF DISCHARGE CAUSE(S) <br />U y <br />;e <br />TANK LEAK ��nw�wyly ❑ --V,--,.FILL RLcP oai7ClrAILJnE ❑ SFiLI <br />m v <br />® PIPING LEAK ❑ OTHER I ❑ CORROSION UNKNOWN ❑ OTHER <br />N wa <br />CHECK ONE ONLY <br />U �: <br />0 UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY <br />w j2 <br />F7NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIIAToN <br />tr <br />w <br />❑AK LEBEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br />v <br />❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ® CLEANUP UNDERWAY <br />J <br />CHECK APPROPRIATE ACTION(S) EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED 810 DEGRADATION (IT) <br />1M SA=KM WMA FRI <br />wQ <br />❑ CAP SITE (CD) -1EXCAVATE b TREAT (ET) ❑ PUMP 8 TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />Lu a <br />❑ CONTAINMENT BARRIER (CB) ❑ NO ACTION REQUIRED (NA) ❑ TREATMENT AT HOOKUP (HU) ❑ VENT SOIL (VS) <br />❑ VACUUM EXTRACT (VE) ❑ OTHER (OT) <br />V'% w \N'-\\- vv e w <br />CC,r w, S \-L er . <br />CC', K,Cha,�s-C�e. 6o;l <br />aw <br />o", CIP �U�n ��' N� ` <br />N <br />