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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 /> ❑ YES ❑l NG REPORT BEEN FILED 7 YES NO 'HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT l HAVE <br /> REPORTED THIS INF TION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> REPORT DATE - --_ CASE THE HEALTH AN CODE <br /> M o O r ?Y SIGNEDDATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNA <br /> w REPRESENT ❑ OWNER/OPERATOR �� REGIONAL BOARD COMPANYOR AGENCY NAME <br /> ¢ LOCAL AGENCY ❑ OTHER <br /> ° <br /> ¢ ADDRESS <br /> /6 STREET / <br /> �SPt/ <br /> NAME CITY STATE // n ZIP- <br /> CONTACT <br /> CONTACT <br /> /J PERSON PHONE <br /> _ /C fJ � UNKNOWN <br /> ¢ ) <br /> �_ <br /> R a ADDRESS — -- - <br /> Lo <br /> w / /J <br /> ¢ /n /�//ma�yy �// ,/ A <br /> /W STREET w/�{�T CfTY / STATE /� ! ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br />'`•' < ADDRESSSj 7 <br /> _. STREET "' • /TL'r/ CRV <br /> � CROSS STREET TYPE OF AREA � COUNTY P <br /> ❑COMMERCIAL ❑ INDUSTRIAL RURAL TYPE OF BUSINESS RETAIL FUEL STATION <br /> D RESIDENTIAL OTHER � FARM ❑ OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> w REGIONAL BOARD - <br /> CL a PHONE <br /> w (�) NAME QUANTITY LOST(GALLONS) <br /> [J�UNKNOWN <br /> 0 (7) -- <br /> ❑ UNKNOWN <br /> w DATE DISCOVERED ,/ HOW DISCOVERED El INVENTORYCONTROL SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> D n x TANK TEST /TANK REMOVAL OTHER <br /> M o o v v _ <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M M DI DI vL_. UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK CLOSE TANK <br /> p HAS DISC GE BEEN STOPPED 7 ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> o YES ❑ NO IF YES,DATEM M V Y ❑ OTHER <br /> � D D <br /> w SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK UNKNOWN GAL, FIBERGLASS---- F <br /> ❑ a OVERFILL ❑ RUPTURE/FAILURE <br /> 2 ❑ PIPING LEAK AGE -- -- YRS a STEEL ❑ CORROSION �UNKNOWN <br /> 9 E-1 OTHER [L;�NKNOWN a OTHER <br /> SPILL 0 OTHER <br /> w w CHECK ONE ONLY <br /> UCL <br /> ❑ UNDETERMINED ❑ SOIL ONLYGROUNDWATER ❑ DRINKING WATER (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> zN <br /> Q a ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> ¢r <br /> v " ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP Ai NATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) y <br /> z CAP SITE CD <br /> o p ❑ ( ) EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) LACEDBIO DEGRADATION(IT) <br /> Lu <br /> w CONTAINMENTBARRIER(CB) EXCAVATE&TREAT(ET) ❑ PUMP&TREATGROUNDWATERSrEN <br /> CE SUPPLY IRS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) EV�DTHER(0-0cn <br /> ,S e <br /> HSC 05(187) <br />