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.-Pq -R'r• s•. s.,ewl. ar.. ,i +. .! k;x�f!'rn n,.JWM-4P-F4 prllG4 <br /> v2u <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 [ONO REPORT BEEN FILED? ❑YES ❑ NO I HEREI3Y CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT G HAVE <br /> REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> REPORT DATE FE# THE HEALTH AND SAFTY CODE. <br /> M M D D v v SIGNED : DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> m <br /> REPRESENTING F-1OWNER/OPERATOR F—] REGIONALOR AGENCY NAME REGIONAL BOARD <br /> O ❑ LOCAL AGENCY ❑ OTHER <br /> CL <br /> cr ADDRESS ] <br /> STREET CITY STATE zr <br /> NAME CONTACTPERSON P PHONE <br /> Ul <br /> co <br /> Fn�: ❑ UNKNOWN <br /> Z <br /> R a ADDRESSrn <br /> cr <br /> STREET CRy STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE j <br /> a ADDRESS <br /> J STREET �'bITy COUNTY ZIP <br /> rn <br /> CROSS STREET TYPE OF AREA ❑COMMERCIAL 0 INDUSTRIAL RURAL TYPE OF BUSINESS, ❑ RETAIL FUEL STATION <br /> ^ ❑RESIDENTIAL ❑OTHER FARM UlOTHER <br /> LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> i <br /> w <br /> z <br /> w <br /> wLuREGIONAL BOARD PHONE <br /> (1) NAME QUANTITY LOST(GALLONS) <br /> W <br /> GNKNOWN <br /> J � <br /> u�O (2) <br /> �.. y ❑ UNKNOWN <br /> Y ~ DATE DISCOVERED HOW DISCOyERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> �= z <br /> F- M M D D y y <br /> El TANK TEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN �/ METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M M D o v y I_,-�J UNKNOWN <br /> ❑ REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> p HAS DISCHARGE BEEN�TOPPED? ❑�/REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> o ❑ YES ❑ NO IF YES, [:DATE M M D D v y ( OTHE R <br /> w SOURCE OF DISCHARGE TANKS ONLYICAPACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK ❑ UNKNOWN GAL. 0 FIBERGLASS O OVERFILL O RUPTURE/FAILURE <br /> ❑ PIPING LEAK AGE YRS ❑"'STEEL ❑ CORROSION ❑ UNKNOWN <br /> ❑ OTHER O UNKNOWN O OTHER a SPILL OTHER <br /> ww CHECKONEONLY <br /> ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONEONLY <br /> Zy <br /> SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> U N ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> O O ❑ CAP SITE(CD) F—] EXCAVATE 8 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) E:] ENHANCED BIODEGRADATION(IT) <br /> w ❑ CONTAINMENT BARRIER(CB) F—] EXCAVATE8 TREAT(ET) ❑ PUMP TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> *�. . �'=1` '�I lr��;1„ )'LL�t...{�ti ;�Jz,.�'��-•��-,1 ..�; ,-,1 -�� '� �t�JI ;,� y + _�/ i f� �� • :: �; -j�f�y � � . _. f° a �. <br /> r „` ' ✓7 r j'1 Y(' �' -2�-C ' S �, t"c�f/TkttL <br /> 4� <br /> r' <br />