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ck t <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SER FOR LOCAL.AGENCY USE ONLY <br /> REPORT BEEN FILED 7 1 HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TOT HE <br /> F-1YESdN0 ❑ YES NO <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM. <br /> REPORT DATE �tCASE X <br /> t-IY >SIGNED <br /> DATE.> <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATOR <br /> 4 <br /> J ��� ) 6 --� YU <br /> o REPRESENTING F-1 OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NA <br /> ¢ �LOCALAGENCY ❑ OTHER c H <br /> Oa �,.t' C�4/L <br /> w ADDRESS � �+ <br /> ® i STREET �� 1// Cm v STATE ZIP' <br /> w NAM !OWPN PHONE <br /> z ❑ UNKNOWN <br /> o¢ <br /> a< ADDRESS <br /> Na _ ` <br /> cr w STREET Ofi " I UJ' cm l/C. ST ZIP75 it <br /> FACILITY NAME(IF PPLICABLE) OPERATOR r PHONE <br /> o �,� C Sof' �✓i d 0 ( ) $ --OS-7 <br /> U <br /> ADDRESSi�c l <br /> O <br /> STREET �V�N Jm � COUNTY 1fa� 21P <br /> ~ CROSS STREET f p 1 <br /> Fe')v — -s-- 6. <br /> O LOCAL AGENCY AGENCY NAME CONTACTPERSON PHONE <br /> z E L l gnu c ) IC)V' s�/ <br /> ww REGIONAL BOAfib PHONE O <br /> CL <br /> U) (1) NAME QUANTITY LOST(GALLONS) 1 <br /> o <br /> aJ - < ��KNOWN <br /> Rai <br /> ? (2) ^ <br /> U) � _ !/ T e 1 7 13, UNKNOWN <br /> Z DATE DISCOVERS HOW DI COVERED ❑ I ENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> w MI/ MI ZDI I D1 Ov /Y ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> a <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGF-.(CHECK ALL THAT APPLY) <br /> 2UNKNOWN E:]REMOVE CONTENTS CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> Lu <br /> M M D D Y Y <br /> Lu HAS DISC.ARGE BEEN STOPPED? REPA <br /> IR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> 0 <br /> YES ❑ NO IF YES,DATE 1.11 MI 4 D J D 0Yl Y ❑REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> w <br /> ¢ <br /> j ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE SPILL <br /> c U ❑ PIPING LEAK ❑ OTHER ❑ CORROSION �NKNOWN ❑ OTHER <br /> N nw. CHECK ONE ONLY <br /> U ❑ UNDETERMINED ❑ SOIL ONLY [�GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> ¢ <br /> 0 c ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) �C�LEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> ISEE BACK TOR MTAIS) <br /> a Z ❑ <br /> 50 CAP SITE(CD) ❑ EXCAVATE 8 TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> 2 a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) TREATMENT ATHOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) BOTHER(OT) �u(11Av Lip 1-0 1 <br /> z1'f Cyt O r G -C�1 �� <br /> m /1°Artrrl L zc� SGS <br /> ob <br /> U <br /> HSC 05(8/90) <br />