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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED 7 YES NO 1 HEREBY CERTIFY?HAT I HAVE DISTRIBU7EDTHIS INFORMATION ACCORDING TOTHE <br /> Q YES No :DISTRIBUTION SHOWN ON THE W.0vipf ION SHEET ON THE BACK PAGE OF THIS FORM <br /> 14. <br /> 17 <br /> REPORT DATE CASE i <br /> D rr >SIGNED DATE <br /> vM V M <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> m <br /> w REPRE ENT 0 OWNER/OPERATOR 0 REGIONAL BOARD MPANY OR AGENCY NAME <br /> g LOCAL AGENCY Q OTHER ,�actui�A ,A U) c/��np� <br /> Q ADDRESS <br /> srAtlE J nv <br /> NAME CONTACTPERSON PHONE <br /> J <br /> Z cr <br /> a UNKNOWN <br /> H OCLa ADDRESS <br /> tu <br /> ¢ STREET cm STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR �` PHONE <br /> (Q (z--1) <br /> a ADDRESS , d q U,; \ <br /> (, <br /> C3 (/fy So., 1 �LC�YICrTy NT np <br /> w <br /> m� CROSS STREET <br /> �y LOCAL AGENCY AGENCY NAME CONTACT PERS N PHONE <br /> Z W �4 rAA <br /> w wEGIONALBOARD PHONE <br /> 0.a ( ) <br /> y (�) NAME QUANTITY LOST(GALLONS) <br /> U W 0 UNKNOWN W <br /> Nm <br /> D O> (2) <br /> 0 <br /> UNKNOWN <br /> DATE DISCOVERED HOW DISCOVERED O INVENTORY CONTROL 0 SUBSURFACE MONITORING Q NUISANCE CONDITIONS <br /> z <br /> w �► O <br /> O I `` 3 C� PL E] TANK TEST a TANK REMOVAL a OTHER <br /> W MI I MI D Y Y <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Q UNKNOWN <br /> w �REMOVE CONTENTS O CLOSE TANK E REMOVE Q REPAIR PIPING <br /> M D Y <br /> p HAS DISCHARGE BEEN STOPPED 7 a REPAIR TANK 0 CLOSE TANK b FILL IN PLACE CHANGE PROCEDURE <br /> H REPLACE TANK OTHER <br /> o YES 0 NO IF YES.DATE 6 M�j D v 2 r 0 <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ¢j F-� TANK LEAK 0 UNKNOWN 0 OVERFILL 0 RUPTUREIFAILURE a SPILL <br /> U �B PIPING LEAK OTHER O CORROSION Q UNKNOWN Q OTHER. <br /> w w CHECK ONE ONLY <br /> v� � UNDETERMINED 0 SOIL ONLY a GROUNDWATER Q DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z1 NO ACTION TAKEN a PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED O POLLUTION CHARACTERIZATION <br /> U)iR <br /> jP F LEAK BEING CONFIRMED 0 PRELIMINARY SITE ASSESSMENT UNDERWAY 0 POST CLEANUP MONITORING IN PROGRESS <br /> U mREMEDIATION PLAN O CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) Q CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) O EXCAVATE b DISPOSE(ED) a REMOVE FREE PRODUCT(FP) Q ENHANCED BIODEGRADATION(IT) <br /> a Z (�RACK� � PUMP E TREAT GROUNDWATER(GT)Q REPLACE SUPPLY(RS) <br /> 80 0 CAP SITE(CO) Q EXCAVATE 6 TREAT(ET) Q <br /> w LU <br /> o O CONTAINMENT BARRIER(CB) NO ACTON REQUIRED(NA) TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> ¢ F-1 VACUUM EXTRACT(VE) 0 OTHER(OT) <br /> N <br /> z <br /> 2 <br /> W <br /> 0 <br /> O <br /> U <br /> HSC 05(&W <br />