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�4� 1 c�cr7 <br />9 /1u � �o <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (C AKY7-CONTAMINATION SITE REPORT <br />(EMERGENCY%NO HAS STATE OFFICE OF EMERGENCY SERV) FOR LOCAL AGENCY USE ONLY <br />REPORT BEEN FILED 7 } HEREBY CERTIFY THAT I AM A DESIGNATED GOVERWEN7 EMPLOYEE AND THAT I NAVE <br />+�Jf <br />U YES YES Np <br />REPORTED THIS INFORMATION TO LOCAL. OFFICIALS PURSUANT TO- SECTION 25180.7 OF <br />REPORT DA1 : CASE i <br />�19TMf.'�CLu�7(3' <br />u o YI r SIGNED DATE <br />TU <br />N OF INDIVIDUAL FILING REPORT PHONE SIG <br />C <br />ING ❑REGIONAL8CARD <br />OWNER <br />OPEATORo REZZAL <br />COMPANY OA fAIGE✓�NCY—NACA <br />� <br />O <br />AGENCYQ OTHER <br />CL <br />Li <br />ADDRESS ECoQ �1 r� t� S�z ' f C� 95206 <br />$TAFFY flTY STATE ZIP <br />NAME <br />-rhe - nN/� � 49y <br />CONTACTPPEER�SON <br />rPHONE Q f/ <br />,,j <br />❑ UNKNOWN <br />Lu <br />cr <br />STaEET / CRY STATE Z1p <br />FACILITY NAME (IF APPLIC LE) <br />l�r,�1� She 22q 3-iq// -7 <br />OPE TflRPHONE <br />`indl✓r �a � 009) �s9 <br />U <br />RE b 4l 9 /n d til b 6111d. <br />A2111d. T. <br />STREET CRY CAUrRY P <br />vCROSS <br />STREEE <br />'r <br />TYPE OF AREA L:] COMMERCIAL 0 INDUSTRIAL ❑ RURAL <br />TYPE OF BUSINESS RETAIL FUEL STATION <br />❑RESIDENTIAL ❑OTHER <br />❑ FARM ❑ OTHER <br />LOC/i�j(I.AGENCY f� AGENCY NAME <br />CONTACT PERSON <br />!PHONE <br />z�EH <br />w <br />n.l <br />REGIONAL BOARD <br />/PHONE <br />LuW <br />(1)� NAME QUANTITY LOST (GALLO <br />l�Q�f'RJp �I �'J 2 <br />J <br />U UNKNOWN <br />Z <br />❑ UNKNOWN <br />Z <br />Lu <br />DJC}TE DISCOVERED J/,� <br />�v <br />HOW DI RED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br />I <br />�LJY <br />V M�M o <br />TANK TEST ❑ TAMC REMOVAL ❑ OTHER <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE {CHECK ALL THAT APPLY) <br />ccE?/UNKNpWN <br />� <br />Lu <br />M M D 0 V Y <br />❑ REMOVE CONTENTS ❑ REPLACE TANK 0 CLOSE TANK <br />❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br />HAS DISCHARGE BEEN STOPPED 7 OKNOW <br />7> <br />YES LJ NO IF YES. DAiTe MI M 01 of Y Y <br />� vi'E' <br />u <br />SOURCE OF DISCHARGE <br />❑ TANK LEAK VNKNONRJ <br />TANKS ONLYC�APACITY MATERIAL <br />0� 000 GAL, ❑ IBERGLASS <br />CAUSE(S) <br />❑ OVERFILL ❑ RUPTUREFAILURE <br />PIPING LEAK <br />AGE YRS VTEEL <br />❑ CORROSION ❑ UNKNOWN <br />❑ OTHER <br />UNKNOWN ❑ OTHER <br />❑ SPILL ❑ OTHER <br />w w <br />a <br />CHECK E ONLY <br />CHECK <br />y <br />❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER • (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY <br />2 y <br />Lu <br />❑ SITE INVESTIGATION IN PROGRESS (DEFINING EXTENT OF PROBLEM) ❑ CLEANUP fN PROGRESS ❑ SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) <br />v H <br />❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVALASLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br />CHECK APPROPRIATE ACTION(S) (SEE BACK FOR DETAILS) <br />n❑ <br />CAP SITE (CD) ❑ EXCAVATE 6 DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) Q ENHANCED BIO DEGRADATION (IT) <br />2 <br />❑ CONTAINMENT BARRIER (CB) ❑ EXCAVATE 6 TREAT (ET) ❑ PUMPS TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />❑ TREATMENT AT HOOKUP (HU) ❑ NO ACTION REQUIRED (NA) ❑ OTHER (OT) <br />&).2,�1i' <br />tri �rrd q�at#rtl� 4f^ 07 <br />w <br />HSC 051"m <br />