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4 Chevron <br />Chevron U.S.A. Inc. <br />UNAUTHORIZED RELEASE REPORT <br />S/S #: BUSINESS NAME: <br />ADDRESS: <br />TANK #: _ <br />PRODUCT: <br />CAPACITY: <br />TO RF COMPLETED BY THE DEALER <br />Date leak was discovered: <br />Approximate dote leak began: <br />Describe fully the cause of the leak: <br />How was the leak discovered? <br />Tn RF COMPI ETD BY CHEVRON MAINTENANCE <br />Hos the leak been stopped? <br />How was the leak stopNed? <br />Date: <br />Complete this form <br />in the event of o <br />confirmed leok 01 <br />spill and send to <br />Chevron within <br />24 hours. <br />List resources effected?: Yes . No Threatened # of wells <br />Soil — <br />Creek or Storm drains — <br />Buildings or Uitlity Vaults — <br />Groundwater — <br />Public Drinking Water — <br />Private Drinking Water — <br />A ricultural — <br />9 <br />Other — <br />Instructions to Chevron Maintenance: <br />This form must be forwarded to appropriate personnel <br />IMMEDIATELY so they can submit to the op.apropriete <br />local agency within 5 days of discovery of any leak. <br />8-91 CHEVF.DWG <br />