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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAIL STATE DFFIDEOFEMERGENCYSERVICES LOCA4AGENCYMOW, <br /> REPORT BEEN FLED T 1, MIT I AM A pE$Ky{II W-4-'Nk*f EI�l1DrEE AND THAT 1 AvI5 <br /> YES NO YES ( d THIs NKO mpm TO RrA aTcw8 NNISUANT TO mcnDN 251!0.7 OF <br /> REPORT DATE CASES THBNFJILTHANOSAFTYCDDE <br /> UAR 'o�curred Drior to 1-1-87 <br /> M YI 8Y1 SIONw'? DATE <br /> NAME OF INDIVIDUAL FLING REPORT PHONE TUBE <br /> Diane M. Hinson ( 209468-3441 <br /> REPRESENTING O.OW)ER OPERATOR Q .REGIONAL BOARD COMPANY OR AGENCY NAME <br /> ®cLODALAGENCY OTHER San Joaquin Local Health District <br /> ADDRESS <br /> 101 ymu E. Hazelton Avenue aT Stockton .,ATEA 9 O5 <br /> NAME CONTA:TPERSON P/IONE <br /> a Roberts Petroleum Services, IncF-1UNKNOWN Bruce Woolsey (209)334-3967 <br /> y ADDRESS <br /> P. 0. Box 347 Lodi „ATE CA 2&5241 <br /> FACILITY NAME IF APPLICABLE) OPERATOR PHONE <br /> Roberts Petroleum Services, Inc. same (209) 334-3967 <br /> ADDRESS <br /> 930 E. Victor Road Lodi San Joaquin 95240 <br /> 5 CROSS STREET TYPE OF AREA a COMMERCIAL[0NDUsTRIAL O RURAL TYPE OF BUSINESS O RETAIL FUEL STATION <br /> . Hwv 99 O RESDENTX E:j OTHER I a FARM MOTHER distributor <br /> LOCALAGENCY AGENCYNAME CONTACT PERSON PHONE <br /> San Joa in Local Health District Laurie Cotulla (209)468-3423 <br /> REGIONAL BOARD PSE <br /> s Region Water - Central Valley - Sac. A. Vorster (916)361-5600 <br /> wq (1) NAME OUANTITV LOST(GALONS) <br /> S Gasoline [ (UNKNOWN <br /> (a <br /> Diesel �UWIXYAN <br /> t DATEDOCOVERED IOW DISCOVERED O NVENTORVCONTROL SUBSURFACEMONITORNO Ej NUISANCE pONDITONS <br /> 0 .1 5 .11 0 0 8v 5 Y TANK TEST O TANK REMOVAL ® OTHER site rnnstrLlrtion <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> ml ml 01 01r11 QxUNKNOWN REMOVECONTENTS O REPLACE TANK O CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED T unknown Q REPAIRTANK REPAIRPPNG O CHANGE PROCELIURE <br /> O VES f-1 NO FYES,OATE M .10 o v r ® OTHER unknown <br /> SOIRCE OF DISCHARGE TANKS ONLY,CAPACITY MATERIAL CAUSES) <br /> O TANK LEAK Ia UNKNOWN 10-Dnn GAL. O FIBERGLASS a OVERFILL a RLPTURNEFALURE <br /> O PIPINGLEAK AGE YRS D STEEL O CORROSION ® UNKNOWN <br /> O OTHER ED UNKNOWN M OTHER abovegrd. O SPILL O OTHER <br /> ywy� CHECK ONE ONLY <br /> f7� 0 UNDETERMINED a SOIL ONLY ® GROUNDWATER DRINKINGWATER. (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F <br /> CHECK ONE ONLY <br /> x♦Sp1 SITE INVESTIGATION IN PROGRESS(OEFNNG EXTENT OF PROBLEM) O CLEANUPINPROGRESSO SIONEDOFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> mg <br /> 8tl1 O NOACTIONTAKEN O POST CLEANUP MONITORING N PROGRESS O NO FUNDS AVAILABLE TOPROCEED O EVALUATNGCLEANLPALTERNAT1VEs <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> O CAP SITE(COI EXCAVATE&DISPOSE REMOVE FREE PRODUCT <br /> (FP)(ED) Q (FP) O ENHANCED BD DEGRADATION(In <br /> Y O CONTAINMENT BARRIER(CS) O EXCAVATE&TREAT(ET) O PUMP&TREAT GROUNDWATER(GT) REPLACESUPPLY(RS) <br /> O TREATMENT AT HOOKUP(HU) O NOA;TKNNREOUIRED(NA) O OTHER(OT) <br /> wcalwl <br />