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f�66¢uti[�Cl <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINA IOII�S <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />FOR LOCAL AGENCY USE ONLY <br />4� <br />F—] YES 0 NO REPORT BEEN FILED? ❑ YEs X NO <br />I EPHEREBY CERTIFY THAT I AM A DESIGNATED GOVEI�Iiu,I <br />�1�1 <br />RORTED THIS INFORMATION TO LOCAL OFFICIALS PU d 07 OF <br />THE HEALTH AND SAFTY CODE, ' <br />REPORT DATECASE <br /># <br />1 2 2 2 8 8 <br />SIGNED DATE <br />M M D D V Y <br />NAME OF INDIVIDUAL FILING REPORT <br />PHONE <br />SIG TU-RE <br />Y <br />David L. Brown <br />(40$ 984-6536 <br />��( <br />w <br />REPRESENTING X] OWNER/OPERATOR ❑ REGIONAL BOARD <br />COMPANY OR NAME <br />Cr <br />LOCALAGENCY ❑ OTHER <br />Pacific Environmental Group, Inc. <br />Q- <br />¢ <br />ADDRESS <br />1601 Civic Center Drive, Suite 202, Santa Clara, CA 95050 <br />STREET CITY STATE ZIP <br />NAME <br />CONTACTPERSON <br />PHONE <br />z� <br />ARCO Petroleum Products ❑ UNKNOWN <br />Mr. Kyle Christie <br />(415) 571-2434 <br />Cr <br />Ra <br />ADDRESS <br />It <br />2000 Alameda de las Pulgas, Suite 218, San Mateo, CA 94402 <br />STREET CITY STATE 2I <br />FACILITY NAME (IF APPLICABLE) <br />OPERATOR <br />PHONE <br />z <br />ARCO Station #4932 <br />JAmes M. Bartlett <br />�(209)465-9515 <br />0 <br />a <br />ADDRESS <br />16 E. Harding WaSE�Stockton, San Joaquin 95205 COUNTY ZIP <br />TYPE OF BUSINESS <br />Fn <br />CROSS STREET <br />TYPE OF AREA ® COMMERCIAL ❑ INDUSTRIAL ❑ RURAL <br />❑ RETAIL FUEL STATION <br />Center <br />❑ RESIDENTIAL ❑ OTHER <br />❑ FARM ❑ OTHER <br />LOCALAGENCY AGENCY NAME <br />CONTACTPERSON <br />PHONE <br />ZW�.7 <br />San Joaquin Local Health District <br />Ms. Lori Cotulla <br />(209)468-3420 <br />W w <br />REGIONAL BOARD <br />PHONE <br />a <br />Central Valley Region <br />Lee Boggs <br />(916)361-5740 <br />(1) NAME QUANTITY LOST (GALLONS) <br />WO <br />Unleaded gasoline approx. 1 gall. ❑ UNKNOWN <br />Zw <br />J <br />Q <br />v� 00 <br />(2) <br />_- <br />❑ UNKNOWN <br />z <br />DATE DISCOVERED <br />HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br />1 M1 2 .1 2 D1 2 D 887, <br />❑ TANK TEST ❑ TANK REMOVAL OTHER <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />} <br />¢ <br />12 2 2 8 8 E::] UNKNOWN <br />M M D D Y Y <br />E:]REMOVECONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br />p <br />REPAIR TANK REPAIR PIPING CHANGE PROCEDURE <br />HAS DISCHARGE BEEN STOPPED? <br />p <br />YES ❑ NO IFYES,DATE 1 2 2 2 8 8 <br />❑ OTHER maintenance completed <br />M M D D V Y <br />w <br />SOURCE OF DISCHARGE <br />TANKS ONLY/CAPACITY MATERIAL <br />CAUSE(S) <br />❑ TANK LEAK ❑ UNKNOWN <br />GAL. E] FIBERGLASS <br />❑ OVERFILL ❑ RUPTURE/FAILURE <br />❑ PIPING LEAK <br />AGE YRS ❑ STEEL <br />❑ CORROSION ❑ UNKNOWN <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 />z <br />Q < <br />❑ SITE INVESTIGATION IN PROGRESS (DEFINING EXTENT OF PROBLEM) X❑ CLEANUP IN PROGRESS E:]SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) <br />cr <br />0 <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 />4 z <br />❑ CAP SITE (CD) ® EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) <br />00 <br />W <br />❑ CONTAINMENT BARRIER (CB) ❑ EXCAVATE & TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />❑ TREATMENT AT HOOKUP (HU) ❑ NO ACTION REQUIRED (NA) ❑ OTHER (OT) <br />F <br />Approximately 1 gallon of gasoline lost during maintenance. <br />w <br />Approximately 1 QUbic yard of soil excavated <br />HSC 05 (4/87) <br />