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l7 <br /> UNAERGROUNDSTORAGE TANK <br /> UNAUTHORIZED RELEASE (LEAK)/ TAMINATION SITE REPORT <br /> EMERGENCY HAS <br /> TANK IQ <br /> EN <br /> HAS STATE OFFICE OF EMERGENCY SERVICES <br /> ❑ YES nyNO REPORT BEEN FILED? ❑ YES ❑ NO <br /> Cnn REGIONAL BOARD CASE # US EPA ID # <br /> R(E�PORT DATE LOCAL CASE # <br /> M1 6M 2D 1 D 9Y O Y IG TURE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE C <br /> > qr - <br /> O <br /> O REPRESENTING ❑ LOCAL AGENCY ❑ OTHER COMPANY OR AGENCY E <br /> W <br /> OXXOWNER/OPERATOR ❑ REGIONAL BOARD <br /> 0. ADDRESS <br /> p P.O. Box g7REpthrop, CA 95330 CITY STATE 2IP <br /> PHONE <br /> CONTACT PERSON <br /> IF NAMEproperty Owner) ( _ <br /> a` ;? <br /> M Langston ❑ UNKNOWN <br /> W, ADDRESS P.O tTp� 97, Lathrop, CA 95330 CITY STATE ZIP <br /> OPERATOR PHONE <br /> FACILITY NAME IIF APPLICABLE) James M. Langston ( 209 858-2470 <br /> Z Langston's <br /> Q <br /> U ADDRESS 15615 Seventh Street, Lathrop, CA 95330 San Joaquin <br /> CITY COUNTY ZIP <br /> 0 STREET RETAIL FUEL STATION <br /> f <br /> CROSS STREET TYPE OF AREA COMMERCIAL ❑INDUSTRIAL TYPE OF BUSINESS P <br /> m u N ��RESIDENTIAL LI RURAL F]OTHER uIUNKNOWN ❑OTHER <br /> L Street PHONE <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON <br /> 09 468-3468 <br /> San Joaquin <br /> W County Environmental Health Cary <br /> 1 <br /> ZREGIO NAL BOARD 1 <br /> WU <br /> fZ <br /> WW <br /> TSCD ENVIRONMENTAL HE JH <br /> QUANTITY LOST (GALLONS) <br /> W CAS # (ATTACH EXTRA SHEET IF NEEDED NAME _❑UNKNOW <br /> aLID <br /> ; (» I I Leaded Gasoline A <br /> J <br /> N O n UNKNOW <br /> m> <br /> h" (2) <br /> DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL '❑ SUBSURFACE MONITORING <br /> KT 0 6 O 7�CX ROUTINE MONITORING ❑ REMOVAL ❑ NUISANCE CONDITION? 7--] OTHER: <br /> �I- M M l� O V Y <br /> >i METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br /> W2 GATE DISCHARGE BEGAN <br /> >W 0 6 10 4D 9 y O y ❑ UNKNOWN (REMOVE CONTENTS ❑ REPLACE TANK ❑CLOSE TANK <br /> Om HAS DISCHARGE BEEN STO PPE D7 (REPAIR TANK ❑REPAIR PIPING [::]CHANGE PROCEDURES <br /> < `XES NO IF VES, DATE OM 6M lO 5 D 9 V 0 Y ❑OTHER <br /> , GAL <br /> TANKS ONLY/CA PACITV CAUSE(S) <br /> W <br /> SOURCES) OF DISCHARGE UNKNOWN ❑OVERFILL El CORROSION <br /> I 1 <br /> ❑TANK LEAK a] AGE LJ—I YRS. XX UNKNOWN <br /> \ MATERIALRUPTURE/FAILURE E]SPILL <br /> U ❑PIPING LEAK ❑STEEL ❑ FIBERGLASS 5R <br /> 0 ❑OTHER (SPECIFY) ❑OTHER ❑UNKNOWN [-]OTHER - <br /> WATER SUPPLIES AFFECTED T T- <br /> RESOURCESAFFECTED YES NO THREATENED UNKNOWN YES NO ENED KNOWN WELLS <br /> W1- ❑ ED PUBLIC DRINKING 1-J 1 ❑ 11 Jv <br /> AIR (VAPOR) ❑ MV WATER L <br /> W SOIL (V ADOSE ZONE( ❑ ❑ EJ PRIVATE DRINKING ❑ ❑ ❑ IA <br /> W GROUNDWATER ❑ ❑ ❑ WATER <br /> W G SURFACE WATER OR STORM DRAIN ❑ ,�y-y,A1 ❑ INDUSTRIAL ❑ ❑ ❑ ".=r = <br /> UE, BUILDING OR UTILITY VAULT ❑ pnl ❑ ❑ AGRICULTURAL ❑ ❑ ❑ �/J,LyvdJ�'I <br /> 0 OTHER (SPECIFY) LJ ❑ ❑ ❑ OTHER SP <br /> ❑ ❑ ❑ <br /> 0 <br /> W GROUNDWATER BASIN NAME <br /> Q <br /> UNKNOWN <br /> COMMENTS: Leakage resulted from testing performed on 6/14/90 by a Certified Tester. <br /> Owner was not notified of any condition of tank upon Tester leaving job. Loss was <br /> f detected upon standard daily monitoring on 6/15/90. <br /> Z <br /> 0 <br /> UHSC 05 110/88) <br /> COMPLETE AND ATTACH A CLEANUP TRACKING REPORT IF ANY CLEANUP WORK OR PLANNING HAS STARTED <br />