Laserfiche WebLink
0 0 <br /> UNDERGROUND STORAGE TANK(UST)SITE-UNAUTHORIZED RELEASE I CONTAMINATION REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑Yes ®No REPORT BEEN FILED? [�Yes ©No I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> *ADORES$ <br /> CASE if REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> 3-11 -18 THE HEALTHANpSAFETY CODE. <br /> Ni INDIVI SIGNED <br /> m tinFIL(NG REPORT PHONE SIGNATURE DATE <br /> g (209)834-1220NTING COMPANYORAGECYAGENCY ❑REGIONALBOARpRIOPERATOR ❑bTHERTracy Petro <br /> 3400 MacArthur Blvd <br /> STREET Tracy CA 85376 <br /> CITY <br /> W NAME STATE ZIP <br /> _Q CONTACT PERSON PHONE <br /> mp 9 Unknown <br /> 6x ADDRESS <br /> fn <br /> ILL <br /> 9X <br /> STREET C17Y <br /> FACILITY NAME(IF APPLICABLE) STATE ZIP <br /> OPERATOR PHONE <br /> Tracy Petro Karam Singh (208) 834-1220 <br /> 6 ADDRESS <br /> s 3400 MacArthur Blvd <br /> Tracy C <br /> CROSS STREI=T STREET CITY y COUNTY A 95376 <br /> ZIP <br /> LOCAL AGENCY AGENCY NAME <br /> z PHONE <br /> San Joaquin E H D ( )(209)953-7311 <br /> F W <br /> 2z <br /> tj in <br /> W REGIONAL BOARD <br /> E c PHONE <br /> WWF a NAME QUANTITY LOST(GALLONS) <br /> mi2) Unknown <br /> E— <br /> N <br /> ❑ Unknown <br /> iDATE DISCOVERED HOW DISCOVERED <br /> W 2-14-18 Tank Test Tank Removal Nuisance Conditions <br /> w <br /> DATE DISCHARGE BEGAN ❑Inventor Control ❑Subsurface Monitoring ❑� Other <br /> g METHOD USED TO STOP DISCHARGJ:(CHECK ALL THAT APPLY) <br /> s ❑Remove Contents ❑ Close Tank <br /> UUW Q Unknown <br /> HAS DISCHARGE SEEN STOPPED? ❑Repair Tank E] Change Procedure <br /> ❑ Replace Tank ■ <br /> � Yes ❑Other <br /> n ❑ ❑ No IF YES,PATE <br /> ❑ Repair Piping <br /> W SOURCE OF DISCHARGE CAUSE(S) <br /> o¢ ❑Tank ❑Piping ❑Dispenser ❑Delivery Problem 115 di <br /> ur u ❑Submersible Turbine Pump(STP) ®Other p [I Overfill ®PhyswallMechanical Damage El Corrasion <br /> ❑Installation Problem ❑Unknown ❑Other <br /> UAW CHECK ONE ONLY <br /> IL <br /> U�- ❑Undetermined ❑Soil Only ❑Groundwater ❑Drinking Water—(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> r CHECK ONE ONLY <br /> Z, <br /> ❑Open-Site Assessment <br /> a ©Oen-Assessment&Interim Remedial ACUon ❑Open-Verification Monitoring <br /> y ❑ <br /> Op -Remediation ❑Open•Inactive <br /> Closed-No Further Action Required <br /> = CHECK APPROPRIATE ACTION(S) <br /> O Human health exposure control? ❑Yes ®No ❑Unknown <br /> a Groundwater migration control? ❑Yes ®No ❑Unknown <br /> w ©No Action Required(NAR) ❑Excavate&Treat(ET) <br /> ❑Excavate 8 Dispose ED ❑Treatment at Hookup(TH} ❑Other <br /> ( ) El Product Removal�FPRJ ❑Replace Supply(RS) <br /> TX UDC filter leak, replaced filter and no additional problems found <br /> m <br /> Z Y <br /> O <br /> tL <br /> Sl'.'RCB Leak Report Form http:/hens.SNvrch.ca.gov/wRtcr_issUeS/progrants/Ust/fornisl <br /> Rev.ozrovzrn z <br />