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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY. <br /> ❑YES :l NO REPORTBEEN FILED? ❑YES ❑ NO I HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTION SHOWN CN THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT DATE CASES n 2 <br /> 7 M 1 9 9 6 S GN DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SI TU E <br /> JERRY YOSHIOKA (209) 468-0335 <br /> REPRESENTING ❑ OWNER/OPERATOR ❑ flEGgNAL BOARD COMPANYOQS(ikNdey ff <br /> 2 ® LOCAL AGENCY ❑ OTHER SAN JyV0A01r�iDJ114/V COUNTY ENVIRONMENTAL HEALTH <br /> a ADDRESS 1� F <br /> 304 E. WEBER Py ,& CnY STOCKTON ,ATE CA 9 ,201 <br /> w NAME CONTACTPERSON PHONE <br /> Or <br /> PI ❑ UNKNOWN ( ) 832-8400 <br /> yn ADDRESS <br /> a 7777 W. ELEVENTH STREET TRACY CA 95376 <br /> STREET CRY STATE "p <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ( 1 <br /> a ADDRESS <br /> Q <br /> w <br /> srRffT Cm SANTA UIN Ip <br /> a-i Cfl055 STREET <br /> CHRISMAN ROAD <br /> LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> w SAN JOA UIN CO. ENVIRONMENTAL HEALTH JERRY YOSHIOKA 5209 ) 468-0335 <br /> w� REGIONAL BOARD PHONE <br /> a a ( ) <br /> 3 <br /> y (t) NAME QUANTITY LOST(GALLONS) <br /> wp <br /> GASOLINE UNKNOWN <br /> m� m <br /> y UNKOWN FUEL ❑ UNKNOWN <br /> i DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> W 7 Ml 1 DI 9 oI 9 r Y ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> m <br /> ® UNKNOWN ®REMOVE CONTENTS ®CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> W M D Y Y <br /> HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> T E�YES ❑ NO IF YES,DATE QW 7 MI 1 ol 9 j 9 Yl 6 Y ❑REPLACE TANK ❑ OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> 10 ® TANK LEAK ® UNKNOWN ❑ OVERFILL ❑ RUPTURHFAILURE ❑ SPILL <br /> a <br /> m0 ❑ PIPING LEAK ❑ OTHER ® CORROSION ® UNKNOWN ❑ OTHER <br /> m i CHECKONEONLY <br /> O ® UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> ¢� ❑ NOACTIONTAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> w ® LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS jL\V <br /> O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) C <br /> I�ame ray miasl <br /> a <br /> In,0 0 ❑ CAP SITE(CD) ❑ EXCAVATES TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> wr <br /> a F--] CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) E::] VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> m <br /> z <br /> z <br /> w <br /> I <br /> 3 <br /> NSD DS IA'sR <br /> `/ `d <br />