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APPENDIX C (� - <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY ,HAS STATE OFFICE OF EMERGENCY SERVICES :FOR LOCAL'AGENCY USE ONLY <br /> ❑ <br /> YES ® NO REPORT BEEN FILED? ❑ YES ® NO .I HEREBY CEFMFYTHAT I HAVEDISTRBUT-eDTHIS WFORMATION ACCORDING TO THE <br /> REPORT DATE CASES DISIMBUTICN SHOWN ON TiE NS HUCTON SHEETON THE BACK PAGE OFTH6 FORM <br /> OJ 8 .-1 1 d 7 J 9 d 8. sc„� wTe <br /> NAME OF INDIVIDUAL FILING REPORT PHONc' $ TURE <br /> Roger Hoffmore 016 ) 364-1880 <br /> w REPRESENTWG ® OWNEr10PERATOR ❑ REGIONAL BOARD I COMPANY OR AGENCY NAME <br /> E ❑ LOCALAGENCY ❑ OTHER SECOR International Incorporated <br /> ADDRESS <br /> 9912 Business Park Drive, Suite 100, Sacramento CA 95827 <br /> ranee+ em r AM n. <br /> w NAME CONTACT PERSON PHONE <br /> a ARCO Products C an ❑ UNKNowN Paul Supple .I ( 510)299-8891 <br /> O ADDRESS <br /> ma <br /> P-0-Box 6549 Mora <br /> ca CAS 94570 <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> o ARCO Station # 4493 ) <br /> i ADDRESS <br /> 0 205 North Center Street Stockton CA 95203 <br /> Y STnEEf FTY CWMfY <br /> m CROS STREET _ <br /> north of Weber Avenue tel, <br /> Z LCCAL AGENCY AGENCY NAME CONTACTPERSON PHONE 1” <br /> w'San Joaquin County Environmental Health Margaret Lagorio (209 ) 468-3449 <br /> 2.. REGONALSCARD PHONE <br /> as Central Valley Region, Sacramento Offic� Mark List (916 ) 255-3132 <br /> w (�) NAME OUANTTY LOST(GALLONS) <br /> 0 <br /> <o MtBE (methyl tertiary-butyl ether) UNKNOWN <br /> m> m <br /> N <br /> ❑ UNKNOWN <br /> DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ® SUBSURFACE MONITORING ❑ NUISANCE CONCITIONS <br /> 2 O d 8 J 1 d 1 DI 9,1 8 Y ❑ TNNKTEsT ❑ TANK REMOVAL ❑ OTHER (sampling of pit wells) <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY)none apply <br /> w MI <br /> 01 x � ® UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&EMOVE ❑REPAIRPIPING <br /> o HAS OMC14ARGE BEEN STOPPED 7 OWn ❑REPAIR TANK - ❑CLOSE TANK&PILL W Pt ACE ❑CHANGE PROCEDURE <br /> C ❑ YES ❑ NO IF YES.DATE MI J of d rI • ❑REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGE <br /> CAUSE(S) <br /> ,c, ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTUREIFA1LURE ❑ SPILL <br /> y 0I ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ® UNKNOWN ❑ OTHER <br /> ww CHECK ONE ONLY <br /> H 6 <br /> O� ❑ UNDETERMINED ❑ SOIL ONLY ® GROUNDWATER ❑ DRINKING WATER•(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> i� ® NOACTIONTAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> POST <br /> UP <br /> LEM BEING <br /> PRELIMINARY SITE ASSESSMT UNDERWAY <br /> JyI ❑ EMEDIATO PIANM� ❑ CASE CLOSED(CLEMUP COMPLETED OR UNNECESSARY) ❑ CLEANUUP UNDERWAY MONITORING IN PROGRESS <br /> O <br /> CHECK APPROPRIATE ON(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCEDBODEGRADATION(IT <br /> 5z <br /> ❑ CAP SITE ICD ❑ EXCAVATE&TREAT(ET) ❑ PUMPS TREAT GROUNDWATER(GT)❑ EPLACE SUPPLY(RS) <br /> awr �^ <br /> s ❑ CONTAINMENT BARRIER(CS) ❑ NO ACTON REQUIRED(NA) ISI TREATMENT ATHOOKUP(HU) ❑ VENTSOL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> 52.4.ug/L MtBE in water reported in one of two underground storage tank pit <br /> w observation wells - TPH-g/BTEX all ND <br /> oFurther assessment will be performed upon removal of the USTs <br /> 0 <br /> C-1 „sFmlwm <br />