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UNDERGROUND STORAGE TONK UNAUTHORIZED RELEASE (LEAK)/GONTAMINATION SITE REPORT <br /> EMERGENCYSTATE TANK ID <br /> Q HAS STATE OFFICE OF EMERGENCY] YE ®VICES O O O O O <br /> YES NO REPORT BEEN FILED? VES NO <br /> REPORT DATELOCAL CASE A REGIONAL BOARD CASE # US EPA ID u <br /> OM 962D 9 D 8 r 6 Y 004515633 <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIG TUBE r, <br /> m Ronald Quick (209 ) 858-5151 <br /> W REPRESENTING Q LOCAL AGENCY 0 OTHER COMPANY OR AGENCY NAM Ir,. <br /> M ® OWNER/OPERATOR Q REGIONAL BOARD LIBBEY OWENS FORD COMPANY <br /> W ADDRESS = <br /> 500 STREET EAST LOUISE AVENUE CITY LATHROP STATE CALIF. zIP9S330 <br /> I > NAME CONTACT PERSON PHONE <br /> 4g LIBBEY OWENS FORD COMPANY 0 UNKNOWN RONALD QUICK ( 209 ) 858-5151 <br /> Oa <br /> "W ADDRESS LOUISE AVENUE STATE ZI LATHROP CALIF. ,95330 <br /> wJ CITY <br /> mm <br /> STREET <br /> FACILITY NAME (IF APPLICABLE) OPERATOR PHONE <br /> o LIBBEY OWENS FORD COMPANY JAMES A. MEYER ( 209 ) 858-5151 <br /> ADDRESS SAN <br /> 500 STREET EAST LOUISE AVENUE CITY LATHROP COUNTY JOAQUIN zI®5330 <br /> F CROSS STREET TYPE OF AREA E] COMMERCIAL ®INDUSTRIAL rTY1PE OF BUSINESS Q RETAIL FUEL STATION <br /> 1-5 E]RESIDENTIAL u RURAL O OTHER UNKNOWN EJOTHERGlaSS mnfcts. <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> San Joaquin Count L. H. D. Laurie Contulla ( 209 )466-6781 <br /> Hw REG TONAL BOARD <br /> '= C. R.W.Q.C.B. Central Valley Region Antonia Vorrester ( 916 )445-0270 <br /> a< TSCD <br /> Dept. of Health Services Charles A. McLaughlin ( 916 ) 322-2337 <br /> W CAS A (ATTACH EXTRA SHEET IF NEEDED) NAME QUANTITY LOST (GALLONS) <br /> UO SEE ATTACHED _K]UNKNOW <br /> a <br /> J <br /> NO <br /> M? �UNKNOW <br /> DATE DISCOVERED HOW DISCOVERED Q INVENTORY CONTROL l Q SUBSURFACE MONITORING <br /> ROUTINE MONITORING TANK LJ NUISANCE CONDITIONS r( OTHER: <br /> �I- OM M D D Y Y D REMOVAL <br /> mZ METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br /> ,W DATE DISCHARGE BEGAN <br /> OF M M D D Y V ® UNKNOWN Q REMOVE CONTENTS REPLACE TANK ®CLOSE TANK <br /> pm HAS DISCHARGE BEEN STOPPED? REPAIR TANK REPAIR PIPING QCHA NGE PROCEDURES <br /> X VES NO IF YES, DATE 1 O MI 9 MI 0 D12 DI 8 Yl 6Y OTHER <br /> SOURCE(S) OF DISCHARGE TANKS ONLY/CAPACITY SR GAL CAUSE(SI <br /> j <br /> TANK LEAK (�' UNKNOWN 1 () OOVERFILL CORROSION <br /> < AGE W YRS. Q UNKNOWN <br /> MATERIAL RUPTURE/FAILURE ]SPILL <br /> W QPIPING LEAK <br /> U ©STEEL Q FIBERGLASS <br /> h <br /> OTHER (SPECIFY) Q OTHER ®UNKNOWN Q OTHER <br /> RESOURCES AFFECTED YES NO THREATENED UNKNOWN WATER SUPPLIES AFFECTEDTHREAT- - <br /> I--� YES NO <br /> ENE <br /> KNOWN WELLS <br /> AIR (VAPQR) Q Q PUBLIC DRINKING El 0 I1 In <br /> 0 0 C� WATER LJ l I LJ <br /> 4 SOIL(VADOSE ZONE) L PRIVATE DRINKING O O O <br /> In <br /> GROUNDWATER El Q Ej ® WATER �^1 <br /> R SURFACE WATER OR STORM DRAIN O 0 ® INDUSTRIAL <br /> W 0 <br /> U, BUILDING OR UTILITY VAULT u O O ® AGRICULTURAL O O <br /> O OTHER (SPECIFY) LJ Q Q OTHER(SPECIFY) 0 0 Q <br /> W <br /> Z GROUNDWATER BASIN NAME <br /> UNKNOWN <br /> COMMENTS: This tank was in the process of being closed as per the U.G.S.T. regulations <br /> and it was not in service at the time of removal. Mr. Dan Moers of the S.J.C.L.H.D. <br /> f was present and his inspection report states that the tank was properly dry iced, <br /> 0 appeared in tact and the soil had a strong odor of petroleum products. <br /> COMPLETE AND ATTACH A CLEANUP TRACKING REPORT IF ANY CLEANUP WORK OR PLANNING HAS STARTED NSC 05 (10/55) <br />