UAR/PROP 65_PRE 2019 - Laserfiche WebLink

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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENCY USE ONLY ; ❑ YES ® NO REPORT BEEN FILED 7 E] YES kZ NO I HEREBY CERTIFY THAT I AM A AGOVERNMENTTED EMPLOYEE A REPORTED THIS INFORMATION TO LOCAL OFFICIALSPURSUANTTO SECTION 25180.7 OF THE HEALTH AND SAFTY CODE. REPORT DATE CASE # 0,1 3 M1 1,14D 9 Y 0 Y SIGNED DATE NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE AS AGENT,FOR ARCO mAlice Scheufler �(408)984-6536 a REPRESENTING ® OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NA 0 a ❑ LOCAL AGENCY ❑ OTHER Pacific Environmental Group, Inc. ¢ ADDRESS 1601 Civic Center Drive #202 Santa Clara CA 95050 STREET CRY STATE ZIP w J NAME CONTACT PERSON PHONE Z ¢ Arco Petroleum Products Co ❑ UNKNOWN Elaine Lavine ( 415) 571-2482 S a ADDRESS w P.O. Box 5811 San Mateo CA 94402 STREET CRY STATE ZIP FACILITY NAME (IF APPLICABLE) OPERATOR PHONE Arco Service Station No. 4932 Navin Patel (209)466-9516 o a ADDRESS 16 East Harding Way StocktonRY San Joag4 vn 95205 STREET ZIP y CROSS STREET TYPE OF AREA COMMERCIAL 0 INDUSTRIAL ❑ RURAL TYPE OF BUSINESS RETAIL FUEL STATION N. Center ❑ RESIDENTIAL ❑ OTHER ❑ FARM 0 OTHER LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE w� San Joaquin Local Health District Mr. Doug Wilson X09 )466-6781 ww Q- R�GIONALB0,4RQ_ entral /alley Region -Sacramento Mr. Lee Boggs P % 361-5740 0) (t) NAME QUANTITY LOST (GALLONS) O W Gasoline ® UNKNOWN zd> J 2 12) ❑ UNKNOWN Z DATE DISCOVERED HOW DISCOVERED F-1INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS 0,13 M1 0 p 9 p1 9 yj 0 Y ❑ TANK TEST 0 TANK REMOVAL ® OTHER Dri VP_ off DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) w O M 3 m10 p 9 p 9 Y O Y ❑ UNKNOWN ❑ REMOVECONTENTS ❑ REPLACE TANK ❑ CLOSE TANK p ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE HAS DISCHARGE BEEN STOPPED ? p ® YES ❑ NO IFYES,DATE OM 3 0 9 9 0 ® OTHER turned safety valve off .1 p 0 Y Y U) SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) 9 ❑ TANK LEAK ❑ UNKNOWN GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ PIPING LEAK AGE YRS ❑ STEEL ❑ CORROSION ❑ UNKNOWN cc 2 OTHER ❑ UNKNOWN ❑ OTHER SPILL ❑ OTHER w w CHECK ONE ONLY N/A CL v ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER • (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CHECK ON'_ONLY s < ❑ SITE INVESTIGATION IN PROGRESS (DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS a SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) 2 H V ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES CHECK APPROPRIATE ACTION(S) (SEE BACK FOR DETAILS) z 00 ❑ CAP SITE (CD) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIODEGRADATION (IT) w� ❑ CONTAINMENT BARRIER (CB) ❑ EXCAVATE 8 TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) cc ❑ TREATMENT AT HOOKUP (HU) ® NO ACTION REQUIRED (NA) ❑ OTHER (OT) Customer drove away with nozzle still in car. Broke nozzle and filter. Dealer Cn W turned safety valve off. Absorbent material was used to clean up spill. Local 2 fire department and OES were contacted. 8 HSC 05 (4�7)