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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY ERVIC 3 FOR LOCAL AGENCY USE ONLY <br /> ❑ YES NO REPORT BEEN FILED? <br /> ❑ YES NO I HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> REPORTDATE CASEt DISTRIBUTIIXJ SHOWN ON <br /> THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> 0 „ 1 7 9 6 Y SGNED <br /> NAME OF INDIVIDUAL FILING REPORT DATE <br /> PHONE SIGNATURE <br /> JERRY YOSHIOKA (209) 468-0335 <br /> w REPRESENTING ❑ OWNERADPERATOR ❑ REGIONAL BOARD <br /> ¢ COMPANY OR AGENCY NAME <br /> g ® LOCAL AGENCY ❑ OTHER SAN JOAQUIN COUNTY ENVIRONMENTAL HEALT <br /> ADDRESS <br /> 304 E. WEBER AVENUE, STOCKTON, CA 95201 <br /> NAME <br /> crtv STATE ZIP <br /> coNTACTPERsoN <br /> w PHONE <br /> SHELL OIL COMPANY (510 )675-6100 <br /> ❑ UNKNOWN <br /> Z¢ <br /> 2 y ADDRESS - <br /> w <br /> S <br /> FACILITY NAME(IF APPLICABLE) aTATE ,v <br /> OPERATOR PHONE <br /> SHELL SERVICE STATION SHELL OIL 010 ) 675-6145 <br /> ADDRESS <br /> 3 3011 BENJAMIN HO DRIVE, STOCKTON, CA Dm95209 <br /> N <br /> CROSS STREET couury ziP <br /> INTERSTATE 5 <br /> i LOCAL AGENCY AGENCY NAMECONTACTPERSON <br /> zw PHS-EHD ;HONE <br /> W , , <br /> w�U <br /> REGK)NAL BOARD <br /> CVRWQCB :F PHONE <br /> NAME 4V QUANTITY LOST(GALLONS) <br /> 2 w (GASOLINE <br /> F 0 <br /> E:] UNKNOWN <br /> mm <br /> N <br /> ❑ UNKNOWN <br /> WDATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> 14 ❑MD 9Y16 Y <br /> TANK TEST TANK REMOVAL ❑ OTHER <br /> Q DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> wM o Y r ® UNKNOWN ❑REMOVE CONTENTS ®CLOSE TANK B REMOVE ❑REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK ❑CLOSE TANK i FILL IN PLACE ❑CHANGE PROCEDURE <br /> o ® YES ❑ NO IF YES,DATE u 0 MI 0 D 9 9 Y 6 r ❑REPLACE TANK ❑ OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ¢j ❑ TANK LEAK ® UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> a <br /> w0 ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ® UNKNOWN ❑ OTHER <br /> w w CHECK ONE ONLY <br /> UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY <br /> z ❑ NO ACTION Tp KEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> m ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE E DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> e.rxrwmiusi <br /> W4 F-1CAP SITE(CDJ E] EXCAVATE&TREAT(ET) F-1PUMP 8 TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> a ❑ CONTAINMENT BARRIER(CB) El ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHERIOT) <br /> z FURTHER SITE ASSESSMENT WILL BE REQUIRED TO DETERMINE THE NATURE AND <br /> EXTENT OF CONTAMINATION AS REQUIRED BY THE APPROPRIATE REGULATORY <br /> g AGENCY. <br /> xsc Ds lass <br />