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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY / HAS STATE OFFICE OF EMERGENCY SERVICF,S FOR LOCAL AGENCY USE ONLY <br /> F-1 YES REPORT BEEN FILED? ❑YES +,—�/ NO I HEREBY.CERTIFY THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> IJ REPORTED THI' MRTM TO LOCAL OFFICIALS PURSUANT TO SECTION 251807 OF. <br /> REPORTDATE CASE# THEH SAFTY CODE, 81� 27 l-qo <br /> -7RrUr M M AT <br /> ATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIG <br /> m ��✓F-,rild- lZmc)�6 -3Nfi <br /> REPRESENTING ❑ OWNER'OPERATOR ❑ REGIONAL BOARD COMPAN��Y((O''R AGENCY NAME <br /> LOCAL AGENCY ❑ OTHER <br /> J�Y✓I N ew• /�V/�^I�-('rFIIFLT �/PV <br /> ADDRESS <br /> ySTREET CRY WATE W <br /> NAME CONTACTPERSON PHONE <br /> H€ f?'A& M 1417FYi !f ❑ UNKNOWN AUK �BiNC�GD (tal l �6��(,7 <br /> y ADDRESS Dw4y� si x-�I� c. Q�zoS <br /> srREEr cm STATE nP <br /> FACLITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> i✓ a. ✓ 5 ! God (�) S6 25 <br /> ADDRESS <br /> /P& O/d 57',v �To1J S„n'�irT � H QIj�rLo <br /> �+ CROSSSTREET <br /> LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> O� (�l-IGr Ecf1l <br /> A4444995 <br /> w REGIONAL BOARD <br /> � PHONE <br /> NAME QUANTITY LOST(GALLONS) <br /> a 1vUNKNOWN <br /> N> <br /> m Z <br /> ❑ UNKNOWN <br /> Z DATEOISCOVERED HO�W7DII/SCOVERED INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCEOONDITONS <br /> 1 . I u Z-o D r v i' TAKKTEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHODI /, MED USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> MI u D 11 r r I—I mo,,,U"KN� ❑ REMOVECONTENTS E::] REPLACETANK ❑ CLOSETANK <br /> HAS DISCHARGE BEEN STOPPED? ❑�REPAIRTANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> c ❑ YES E::] NO IFYES,DATE .1 M o o v Y - <br /> THER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> w ❑ TANKLEAKUNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> ❑ PIPING LEAK ❑ OTHER ❑ CORROSION 0 UNKNOWN ❑ OTHER <br /> ww CHECKONEONLY <br /> ❑ UNDETERMINED dSO1LONLY O GROUNDWATER ❑ DRINKING WATER (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECJ( ONLY <br /> z< NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBM IT TED O POLLUTION CHARACTERIZATION <br /> ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING W PROGRESS <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUPUNDERWAV <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED 810 DEGRADATION(IT) LJ <br /> zpe.cxRnoEraal <br /> wF ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT LET) ❑ PUMPBTREATGROUNDWATER(GT) ❑ REPLACE SUPPLY IRS) <br /> ❑ CONTAINMENT BARRIER LOS) ACTION REQUIRED INA) TREATMENTAT HOOKUP(HU) ❑ VENTSOIL(VS) <br /> EJ VACUUM EXTRACT(VE) LOTHER( OT) <br /> -AT/IIf.,Q r 1VI4 RE R�G2Y/iREO iii �fT6 t�rlE TFF� N dTvr2� ./KD �V <br /> ar'TEN`—oF CcWf-AM(N�IGri/.45 RiSpvtl2j0 64r TWC- APpRoPRjATf- <br /> $ 1R�vc.�aY .6'GF-NAY <br /> Kacoll,t/HR <br />