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001 - u.os <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ YES NO REPORT BEEN FILED 7 E-1YES [:]INO 1 HEREBY CERTIFY THAT I.HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> �y <br /> REPORT�MTE ^ O Y CASE s SIGNED DATE. <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATOR -�;-y-� <br /> Le f; r u. Sr f S cab )WLR 3*61 4g � _ <br /> w REPRESENTING ❑ OWNERIOPERATOR ❑ REGIONAL BOARD C[O�MPANY OR AGENCY NAME s C — h <br /> S LOCAL AGENCY ❑ OTHER P/�sQy� �Q({� �. I `/ E V <br /> m ADDRESS <br /> 30f- 40zo. ?5,v <br /> STREET Cm STATE ZIP <br /> J <br /> NAME 4, CONTACT PERSON PHONE <br /> Gi Ga4• ❑ UNKNOWN F_Rtje ST er;a-�^-, �) ab9 9�►- -b <br /> c7 Vff W <br /> h a ADDRf.SS A c ^ ?5,;1 <br /> 5, 1 <br /> �7 RSrt L �-k za J�Gt, C`/Al(r(vY v ST <br /> STREET Cm STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR .• PHONE <br /> RIU, esGfJI �1� 9,31-dam <br /> a ADDRESS ��A�"�{-y.}�/� � • `�52� � <br /> w Cm couRry nP <br /> y CROSS STREE <br /> O LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> sa�n ' - cvc caa9)'�68 3 9 <br /> w REGIONAL BOAR PHONE <br /> y (1) <br /> NAME <br /> QUANTITY LOST(GALLONS) <br /> UNKNOWN <br /> Z <br /> �o <br /> m <br /> Z 12) Dl <br /> N �� <br /> ❑ UNKNOWN <br /> i DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL �7�❑cyy SUBSURFACE MONITORING ❑ NUISANCE CONDI IONS <br /> OVAL <br /> OTHER_jo& <br /> aDATE DISCHARGE BEGAN oY ' Y ❑TTA/INKTEST ❑ TANK METHOD USED TO ST> OPDSCHARGE(CHECK ALL THAT PL , <br /> w M N o o Y Y L�UNKNOWN ❑REMOVE CONTENTS CLOSE TANK&REMOVE ❑REPAIR PIPING v, <br /> HAS DISCHARGE BEEN STOPPED T �1 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE E]CHANGE PROCEDURE v <br /> YES E:] NO IF YES,DATE Vz , 0 5 Y Y ❑REPLACE TANK ❑ OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ¢j ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> N O ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> w CHECK ONE ONLY <br /> O ❑ UNDETERMINEDSOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> jN ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> ISH MLMRl11 caTAUI <br /> 50 ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP 8 TREAT GROUNDWATER(GT)E::] REPLACE SUPPLY(RS) <br /> w� <br /> w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> i <br /> Olt <br /> HSC 0ISP% <br />