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UNDERGROUND STORAGE T K UNAUTHORIZED RELEASE (LEAK)/66NTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑Yes ®No REPORT BEEN FILED? ®Yes ❑ No I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> REPORT DATE CASE# THE HEALTH AND SAFETY CODE. <br /> 4/20/2011 11-2493 <br /> SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> } Gerardo Acuna (925) 766-6939 <br /> M <br /> o REPRESENTING COMPANY OR AGENCY NAME <br /> UJ <br /> ❑LOCAL AGENCY ❑ REGIONAL BOARD Chevron Products Company <br /> o ®OWNER/OPERATOR ❑OTHER <br /> w ADDRESS <br /> 2003 Diamond Blvd. Concord, CA 94520 <br /> STREET CITY STATE ZIP <br /> wNAME CONTACT PERSON PHONE <br /> ZW <br /> Chevron Products Company ❑Unknown "Permit Desk" (925) 842-9002 <br /> o a ADDRESS <br /> W a PO Box 6004 San Ramon, CA 94583 <br /> W STREET CITY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> 0 Chevron#94275 TChevron Stations, Inc. (209) 478-5555 <br /> a ADDRESS <br /> 0 2905 West Benjamin Holt Dr. Stockton San Joaquin 95207 <br /> LU STREET CITY COUNTY ZIP <br /> CROSS STREET <br /> Blymouth Rd. <br /> LOCAL AGENCY AGENCY NAME PHONE <br /> ZSan Joaquin County- Environmental Helth Dept. (209) 468-3446 <br /> Zw <br /> wo <br /> UJ REGIONAL BOARD PHONE <br /> CL ( ` <br /> (1) NAME QUANTITY LOST(GALLONS) <br /> LU <br /> > gasoline ® Unknown <br /> Q J <br /> m O> (2) <br /> N ❑ Unknown <br /> DATE DISCOVERED HOW DISCOVERED ❑Tank Test ❑Tank Removal ❑Nuisance Conditions <br /> W4/19/2011 ❑Inventory Control ❑Subsurface Monitoring ®Other <br /> m <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> g ❑Remove Contents ❑ Close Tank <br /> w ® UNKNOWN ❑Repair Tank ❑ Change Procedure <br /> o HAS DISCHARGE BEEN STOPPED? ❑ Replace Tank ®Other <br /> L ®YES ❑ NO IF YES,DATE 6/3/2008 ❑ Repair Piping <br /> 0 <br /> wSOURCE OF DISCHARGE CAUSE(S) <br /> j <br /> U w <br /> � <br /> o ❑Tank Leak E]Piping Leak C3 Unknown ®Other ❑Overfill ❑Corrosion ❑ Rupture/Failure ❑Unknown ❑Spill ®Other <br /> WW CHECK ONE ONLY <br /> >- C3Undetermined [:]Soil Only ❑Groundwater E] Drinking Water—(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> ❑No Action Taken ®Case Closed(Cleanup Completed or Unnecessary) <br /> W= <br /> ❑Leak Being Confirmed ❑Pollution Characterization <br /> M' C]Remediation Plan ❑Post Cleanup Monitoring in Progress <br /> L) ❑Preliminary Site Assessment Workplan Submitted ❑Cleanup Underway <br /> ❑Preliminary Site Assessment Underway <br /> CHECK APPROPRIATE ACTION(S) <br /> <z [:1 Cap Site(CD) C1 Excavate&Treat(ET) ❑Treatment At Hookup(HU)ES ®Other <br /> w� <br /> ❑Contamination Barrier(CB) ❑No Action Required(NA) C1 Enhanced Bio Degradation(IT) <br /> a ❑Vacuum Extract(VE) C1Remove Free Product(FP) [3 Replace Supply(RS) <br /> ❑Excavate&Dis ose ED ❑ Pump&Treat Groundwater GT ❑Vent Soil VS <br /> The north side gasoline fuel filter on dispenser 7 was leaking fuel at a rate of approximately one drop every two seconds.The <br /> Z leak was dripping into the under dispenser containment and also stained the concrete outside the dispenser. The testing <br /> UJ <br /> technician on site replaced the fuel filter, removed the liquid from the secondary containment and stopped the leak. All the <br /> 0 following agencies were notified on 4/20/11: NRC #973545, California office of Emergency Services #11-2493 & San <br /> Joaquin County Public Health Services reported to Michele Henry. <br /> UN-028-1/2 www.unidocs.org Rev.10/31/06 <br />