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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 i <br /> ❑ YES NO ❑ YES NO I HEREBY CERTIFYTHAT I.HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> REPORT DATE DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM I` <br /> /� CASE <br /> v M / <br /> NAME OF INDIVIDUALFILING REPORT PHONE SIGNATURE <br /> / O v ( 7 91 Y(o�3 vc, <br /> REPRES ING O OW <br /> ❑ REGIONAL BOARD COMPANYOR AGENCY NA ME <br /> S LOCAL AGENCY ❑ OTHER n To¢ <br /> r ADDRESS <br /> gS2b/ <br /> STREET Cm STATE ZIP <br /> m NAME CONTACjT'[P/ERSON I A 14 1 1 PHO <br /> (� NE <br /> ❑ UNKNOWN �T AN V'Ll/ ` <br /> i a ADDRESS <br /> N n <br /> w /dS7 /ti• yosCi,-,�/* /!'Jcin�cp— CH <br /> a <br /> 9TREE! <br /> FACILITY NAME(IF APPLICABLE) OPERATOR cm sTATE P <br /> O "L " R[l/ litJl l�4 irl r' IG✓// O �/ 'U�iJ <br /> < ADDRESS <br /> 4 /a s7 �, yoE Ei» /!+ /rGr(�/CLa- sr7h✓C��4in <br /> y CRO55 STREET tm 71D .. <br /> ry LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> w <br /> w U l <br /> ww REGIONAL BOARD PHONE <br /> as <br /> � ( I <br /> T NAME <br /> U Q ( QUANTITY LOST(GALLONS) <br /> w <br /> KNOWN <br /> m> m <br /> N <br /> UNKNOWN <br /> i DATE DISCOVERED L� HOW DISCOVERED ❑ I NTORY CONTROL SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> M 6 DI r Y /r ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M D r y ❑ UNKNOWN REMOVE CONTENTS OSE TANK&REMOVE ❑REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE O CHANGE PROCEDURE <br /> o ❑ YES ❑ NO IF YES,DATE REPLACE TANK F-1OTHERM D Y Y <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> �a ❑ TANK LEAK UNKNOWN ❑ OVERFILL RUPTURE/FAILURE O SPILL <br /> O ❑ PIPING EAK O OTHER E] CORROSION O UNKNOWN Q OTHER <br /> m a <br /> CHECK ONLY <br /> O UNDETERMINED ❑ SOIL ONLY GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> ZH ❑ NOACTIONTAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED O POLLUTION CHARACTERIZATION <br /> �y ❑ BEING CONFIRMED O PRELIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS L <br /> O O CLEANUP UNDERWAY <br /> REMEDIATK)N PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) C� <br /> CHECK APPROPRIATE ACTION(S) O EXCAVATE&DISPOSE(ED) E] REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) v <br /> Z 1>+�e�cxrwoEilus/ <br /> WO ❑ CAP SITE(CD) O EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(DR)O REPLACE SUPPLY IRS) <br /> a ❑ CONTAINMENT BARRIER(CB) ❑ NOACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ 44CUUM EXTRACT(VE) Q OTHER(OT) <br /> FLGJ//td! s tr(P asrass.,�a',f rP..�-2d c. ivr. /a..r a.,o Gu/YY.,�Iy u� G(urwa� <br /> IIx os IAAm <br />