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s • <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICESFORLOCALAGENCYUSEONLY <br />REPORT BEEN FILED? � / <br />❑ YES 5klllO <br />I:}IERE$Y G! RT1FY THAT t AM KOESIGNATEO GOVERNMENT EMPLOYEE .pNLt THAT'i HAVE: <br />❑ YES NO <br />RE! T by THiS INFORMATION TO LOCAL::OFFICIALS PURSUANT TO SECTION 251807 DF. <br />THEN A..... Y <br />REPORT DATE <br />CASEi► <br />M M D Y Y <br />81pN Tf <br />NAME OF INDIVIDUAL FILING REPORT <br />PHONE <br />SIGN A RE <br />W <br />Q <br />REPRESE G OWNER/OPERATOR ❑ REGIONAL BOARD <br />COMPANY OR AGENCY NAME <br />c <br />O <br />LOCAL AGENCY ❑ OTHER <br />I ° y <br />a <br />2 <br />ADDRESS <br />STREET CRY STATE ZIP <br />NAME <br />CjO�NT��ACT1PERSON <br />PHONE <br />z <br />y� / <br />N l > C L ❑UNKNOWN <br />W - 1 urx-L G <br />�G�l &-2') <br />Ra <br />ADDRESS <br />-D 'Rftr�CJV <br />cc <br />CITY STATE ZIP <br />FACILITY NAME (IF APPLICABLE) (� <br />OPERATOR <br />PHONE <br />z <br />f rr ( <br />O <br />ADDR�ESSS� <br />140-3 CDU 79.1 6,vf, D <br />STREET CRY COUNTY DP <br />Lu <br />~ <br />CROSS STREET <br />TYPE OF AREA ❑ COMMERCIAL ❑ INDUSTRIAL ❑ RURAL <br />TYPE OF BUSINESS TAIL FUEL STATION <br />kC: <br />RESIDENTIAL ❑OTHER <br />Q FARM ❑ OTHER <br />LOCAL AGENCY AGENCY NAME <br />CONTACT PERSON <br />PHONE <br />w UJ <br />REGIONAL BOARD <br />PHONE <br />(�) NAME QUANTITY LOST (GALLONS) <br />W <br />OZJ W <br />� <br />�.� El—UNKNOWN <br />4 <br />y O <br />N Z <br />(2) <br />❑ UNKNOWN <br />F <br />DATE DISCOVERED <br />HOW DISCOVERED ❑ INVENTORY CONTROL SUBSURFACE MONLTQFjI�G ❑ NUISANCE CONDITIONS <br />5°/�$V� Vim, <br />(fM rM l o ' D y <br />❑ TANK TEST ❑ TANK REMOVAL ❑ OTHER <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />E?"UNKNOWN <br />❑ REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br />w <br />p <br />M M D D Y Y <br />❑ REPAIR TANK REPAIR PIPING ❑ CHANGE PROCEDURE <br />HAS DISCHARGE BEEN STOPPED? <br />p❑ <br />YES I +�'.I NO IF YES, DATE M M o D Y y <br />❑ OTHER <br />w <br />SOURCE OF DISCHARGE <br />TANKS ONLY/CAPACITY MATERIAL <br />CAUSE(S) <br />4 <br />❑ TANK LEAK UNKNOWN <br />GAL. ❑ FIBERGLASS <br />❑ OVERFILL E]RUPTURE/FAILURE <br />2 <br />F—]PIPING LEAK <br />AGE YRS <br />❑ CORROSIONNKNOWN <br />❑ OTHER <br />UNKNOWN ❑ OTHER <br />❑ SPILL ❑ OTHER <br />w w <br />CHECK ONE ONLY <br />❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />F <br />CHECK ONE ONLY <br />Lu <br />4 <br />❑ SITE INVESTIGATION IN PROGRESS (DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) <br />cr <br />U y <br />❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br />CHECK APPROPRIATE ACTION(S) (SEE BACK FOR DETAILS) <br />z <br />F7 CAP SITE (CD) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) <br />w <br />❑ CONTAINMENT BARRIER (CB) ❑ EXCAVATE & TREAT (ET) ❑ PUMP &TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />OTHER (OT) ❑ <br />NO ACTION REQUIRED (NA) TREATMENT AT HOOKUP (HU) ❑ ❑ <br />rN �'irz' R /tip�vr w>LL_ 3 - jR'G�q u l�%> ; <br />zm <br />LJ <br />