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i (j <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY / HAS STATE OFFICE OF EMERGENCY SERVI FOR-LOCALAGENCY USE ONLY <br /> R�{,, REPORT BEEN FILED? <br /> ❑YES Ll "'O YES NO 1 HEREBY CERTIFY.THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE. <br /> REPORTED THIS INFORMATION TO LOCALfiCIA[S PUpSUANT TO SECTION 28780,70E <br /> REPORT/D(ATE \n CASES THE HE"ANDS (CODE [ Q}�. <br /> M /MI Zd 6bI xyl / Y DATE: <br /> SGNED �� <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNA RE <br /> w REPRESENTING ❑ OWNERIOPERATOR ❑. REGIONALBOARD COMPANY OR AGENCY NAME q <br /> pO'LOCALAGENCY ❑ OTHER /` _ •n . <br /> A KESSSaJ`•l�� <br /> Cf(r SATE ZIP <br /> �y NAME CONTACTPERSON <br /> PHONE / p�/ <br /> z¢ _ e, ❑ UNKNOWN (],/�j 3 6 6'/ Z� <br /> S ya ADDRESS <br /> S� �6c a L C aaC, C4 �S L Gp <br /> CrtV STATE LP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> z ( ) <br /> ADDRESS / SLY <br /> L.✓ p/�r � <br /> w u�' sTaeeT cm c\JcWMrZIP <br /> y CROSSSTREET TYPE OF AREA ❑COMMERCIAL ❑ INDUSTRIA RURAL TYPE OF BUSINESS ❑ RETAIL FL&I STATION <br /> ' ❑RESIDENTIAL ❑OTHER ❑ FARM O OTHER/tflj i�,l•K.L <br /> LOCALAGENCY AGENCY NAME CONTACT PERSON / PHONE <br /> w REGIONALSOARD PHONE <br /> Z I <br /> y <br /> (1) NAME OUANTRY LOST(GALLONS) <br /> r1/ - d <br /> Z ((4�` LJ UNKNOWN <br /> a� <br /> NZ V'—V <br /> �' UNKNOWN <br /> r DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL Q SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> z / <br /> M /V o r v ❑ TANKTEST TANK REMOVAL ❑ OTHER <br /> r <br /> DATE DISCHARGE BEGAN I-y METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M M o D y y .i/I UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK CLOSE TANK <br /> p HAS DISCHARGE BEEN STOPPED? r y/y., REPAIRTANK REPAIR PIPING CHANGEPROCEDURE <br /> p <br /> YES O NO IFYES.DATE (/M J N Qo 0 0� Frj� v ❑ OTHER <br /> n SOURCE OF DISCHARGE TANKS ONLYiCAPACITY MATERIAL CAUSES) <br /> ❑ TANK LEAK UNKNOWN 3TOI � GAL FIBERGLASS Q OVERFILL Q RUPTUREFAILURE <br /> 2 ❑ PIPINGLEAK AGE �! YRSjf!jSTEEL ❑ CORROSION L�UNKNOWN ! <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w w CHECK ONE ONLY <br /> U� ❑ UNDETERMINED OIL ONLY ❑ GROUNDWATER ❑. DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY <br /> c ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) . <br /> ¢r <br /> NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTIONS)(SEE BACK FOR DETAILS) <br /> z ❑ <br /> 00 CAP SITE(CD) ❑ E%ORNATE 8 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) O ENHANCED BIO DEGRADATION(IT) <br /> f ❑ CONTAINMENT BARRIER(CS) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(AS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> 2 C{ S T /LtLcL .c Y. ?6- <br /> Alt 6 /1.L <br /> Q <br /> HWM(a91) <br />