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 LOCAL AGENCY USE ONLY. ❑YES O NO REPORTSEENFLEDY ❑YES FX NO I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25100.7 OF REPORTDATE CASE• THE HEALTH AND SAFTY CODE: O'l 9 M 0 8 0 8 v 8 v SGNEO DATE NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE aS rl 2171 POY ARCO David L. Brown (400 984-6536 �Jzaww REPRESENTING ❑ OWNEWOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME O ❑ LOCALAGENCY ❑ OTHER Pacific Environmental Group, Inc. {a'25 ADDRESS 1601 Civic Center Drive, Suite 202, Santa Clara, CA 95050 sT�ET CRY STATE ZIP uJ NAME CONTACTPERSON PHONE ARCO Petroleum Products UNKNOWN Mr. Kyle Christie (415) 571-2434 a ADDRESS 2000 Alameda de las Pulgas, Suite 218, San Mateo, CA 94402 STREET CRY SPATE DIP FACILITY NAME IF APPLICABLE) OPERATOR PHONE ARCO Station #760 David Hildenbrand (209) 368- 7863 ADDRESS 225 So. ChAkee SREEr Lodi San Joaquin 95240 y ap CROSSSTREET TYPE OF AREA a COMMERCIAL ❑INDUSTRIAL ❑RURAL TYPE OF BUSINESS ® RETAIL FUEL STATION Lodi Avenue ®RESIDENTIAL [::]OTHER ❑ FARM ❑ OTHER LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE w an Joaquin Local Health District Lori Cotulla (209A68-3420 w Nl REGIONAL BOARD a YY PHONE Central Valley Lee Boggs (916) 361-5600 w (1) NAME QUANTITY LOST(GALLONS) Waste Oil UNKNOWN (2) ❑ UNKNOWN DATE DISCOVERED HOWDISCOVERED ❑ INVENTORYCONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS 0 M 9 u — D o 8 r 8 v ❑ TANK TEST ® TANK REMOVAL ❑ OTHER RATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) w N u o o v y ❑ UNKNOWN 0 REMOVECONTENTS ❑ REPLACETANK ❑ CLOSE TANK Q HAS DISCHARGE BEEN STOPPED 7 REPAIRTANK REPAIRPPMNG CHANGE PROCEDURE 8 X1 YES E] NO IFYES,DATE uI MI DI 31 Y Y ® OTHER remove tank LLI SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) N ❑ TANK LEAK ❑ UNKNOWN GAL, ❑ FIBERGLASS © OVERFILL ❑ RUPTURE/FAILURE 2 ❑ PIPING LEAK AGE YRS ❑ STEEL ❑ CORROSION ❑ UNKNOWN Q OTHER Overfill X❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER ff CHECKONEONLY ❑ UNDETERMINED ® SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY P WATER WELLS HAVE ACTUALLY BEEN AFFECTED) F CHECKONEONLY N ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) EKCUEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) U w ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ® EVALUATING CLEANUP ALTERNATIVES CHECK APPROPRIATE ACTIONS)(SEE BACK FOR DETAILS) ❑ CAPSITE(CD) 0 EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) O ENHANCED BIO DEGRADATION(IT) ❑ CONTAINMENT BARRIER IDS) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) ❑ TREATMENT ATHOOKUP(HU) ❑ NO ACTION REQUIRED INA) ❑ OTHER(I N W Y HSC0 (4< 7)