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UNDERGROUND STORAGE TA,-t-. UNAUTHORIZED RELEASE (LEAK) / C(.-,AMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFKE OF EMERGENCY SERVICES FOR LOCALAGENCY USE ONLY <br /> REPORT BEEN FLED 7 E HEREBY CERTIFY THAT I AIA A DESIGNATED GCVERNMENT EMPLOYEE AND THAT t HAVE <br /> YES ❑YES ❑ NO REPORTED THIS INFORMATION TO LOCAL OFFICALS PURSUANT TO.SECTION 2518¢1 OF <br /> REPORTOATE CASE. THE HEALT HAND SAFTY CODE <br /> Q uI 6 ul �el `�' J v �r SIGNED. _,Ti <br /> NAME OF INDIVIDUAL FLING REPORT PHONE SIGNATURE <br /> (1 516P-35� 8 I a F G <br /> w REPRESENTING ❑ OWNEfLOPERATOR ❑ REGIONALBOARD <br /> COMPANY OR AGENCY NAME <br /> 0 LOCALAGENCY ❑ OTHER o�Gli7LJc>Q' 4/ii .tl�lG l /{� Sc'rvrce <br /> 2 <br /> ADDRESS <br /> Aar/ E- eve,?P/��UP J/TIC��I1 VATS zm <br /> NAME CONTACT PERSON PHONE <br /> x� G�har/�S JCOGirz,� ❑ UNKNOWNADDRESS <br /> c 3G7,,j /1/, Cie//77yTReET ,m. S�IJC,C/zn HATE �� 7r <br /> FACLITY NAME IF APPLICABLE) OPERATOR I PHONE <br /> ADDRESS <br /> srnEEr cm mp <br /> m I CROSS STREET TYPE OF AR MMERCAL❑ INDUSTRIAL ❑RURAL TYPE OF BUSINESS I❑ RETAIL FUEL STATION <br /> �� -���� ❑RESIDENTIAL t?�OtER ❑ FARM ❑L.�ER <br /> LOCAL AGENCY AGENCY NAME CONTACTPERSON PHONE <br /> ioc �c o,�/ if/, �/ rc Ca,v O � �t `+) v/ 3 <br /> w REGIONAL BOARD /PHONE <br /> H p <br /> (1) NAME QUANTITY LOST(GALLONS) <br /> w OPS [?--DJW(NOWN <br /> Til/P/ J uNKNowN <br /> W DATE DISCOVERED / HOWOISCOVERED ❑ IN NTORV CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> w du Su� ego J o yl Cr ❑ TANK TEST REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METH 00 USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M u o D r v LI ❑ REMOVFCONTENTS ❑ REPLACETANK �C OSE TANK <br /> Q HAS DISCHARGE BEEN STOPPED? ❑ REPAIRTANK ❑ REPAIRPPNG ❑ CHANGE PROCEDURE <br /> p ❑ YES ❑ NO FYES,DATE u oI v r ❑ OTHER <br /> SOURCE OF DISCHARGE TANKS ONLY,CAPACITY MATERIAL CAUSES) <br /> O ❑ TANKLEAK UNKNOWN /OOl� GAL. ❑ FIBE S ❑ OVERFILL ❑ RLPTUREFALURE <br /> U� ❑ PIPING LEAK AGE VPS STEEL ❑ CORROSION Er UNKNOWN <br /> a OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w w CHECK ONE ONLY <br /> a <br /> e�� ❑ UNDETERMINED ❑ SOI,ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY FWATER WELLS HAVE ACTUALLY SEEN AFFECTED) <br /> CHECK ON':ONLY <br /> e 2' ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY, <br /> Owl ❑ NOACTIONTAKEN ❑ POST CLEANUP MCNITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATINGCLEANLPALTERNATNES <br /> CHECK APPROPRIATE ACTIONS)(SEE BACK FOR DETAILS) <br /> a ❑ CAP SITE(CO) ❑ EXCAVATE&DGPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATOON(In <br /> I ❑ CONTAINMENTBARRIER(CB) ❑ EXCAVATE A TREAT(EM ❑ PUMP&TREAT GROUNDWATER(GI) ❑ REPLPOESLPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(IM ❑ NOACTIONREOUIRED(NA) ❑ OTHER(OT) <br /> .4- /TLerTt2ey �o �fCi iiiw Y"A+{ ��4><CG�P 4/tJ <br /> w / <br /> � el�L•i7/ O� C'On flm/nl..��On crs It'�:�,:pq� 6c/ �� /cC4/ !'L�g ltfCc firLy cc��HGc�, <br /> .sc Z,&V, <br />