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Illl <br /> -1y 1111- <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR CQCAI.'AGEMCY USE,C+NLY.,... <br /> YES ® REPORT BEEN FILED 7 YES i HEREgl'CERIIFY`.W E AM.A DESIGNATED U0VEFIWM0 1 EMPLQYEE ANQ fFlAT 3 FL4VE, <br /> ❑ ® REPORTED:THIS':p�FOgNlA71QN TO iOCAL t7FF.CIMS PURSUANT TO SECT.K)N 25IK7 8F_ <br /> REPORTDATE =CASE* Tl{EHEALTHANDSA FIMATI <br /> M M n '.SIGNED <br /> NAME OF INDIVIDUAL FILING REPORT PHONE } SIGNATURE <br /> 01 fnrij <br /> Wo { <br /> -71R9 <br /> REPRESENTING ® OWNER/OPERATOR ❑ REGK)NAL BOARD COMPANY OR AGENCY NAME <br /> ❑ LOCALAGENCY ❑ OTHER I� <br /> Exxon Com an U.S.A. <br /> ADDRESS <br /> 1200 SmithI i� s <br /> 6TREEr Suite 2726 = Houston STATE Texas X7770 <br /> m NAME CONTACTPERSON IPHONE <br /> I <br /> Za Exxon Company, U.S.A. ❑ UNKNOWN C&M Centers.[ (800 ) 992-3647 <br /> a ADDRESS r} itltl <br /> P.O. Box 4415 Houston Texas 7721 f <br /> STREET CITr :I .I ErrATE IIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR } i6 PHONE <br /> RAS #7-3330 <br /> ADDRESS I San <br /> 3128 W. Benjamin Holt Drive cr, StocktonJoaqhin P <br /> �+ CROSSSTREET <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> � Central Valley Region Water Quality Bd. Gordon Lee, Boggs <br /> ( 910 361-5740 <br /> REGIONAL BOARD I i` PHONE <br /> San Joaluin Health Department Donna Heran ( 209 468-3420 <br /> m IS) NAME QUANTITY LOST(GALLONS) <br /> Gasoline Motor Fuel I ❑ , <br /> OWN <br /> _ m l <br /> ❑ UNKNOWN <br /> DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL EX7] SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> O �+ 4 I� 2 D o r r ❑ TAfM TEST ❑ TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED To STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> r} <br /> tr ►� D o r r ® ❑ REMOVE IOOf TENTS I E:] REPLACE TANK ❑ CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED 7 ❑ REPAIR TANK' ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> o ❑ YES ❑ NO IF YES,DATE M1 M1 DI DI Y1 ❑ OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) } I� <br /> m! ❑ TANK LEAK ® UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPELL <br /> ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> it <br /> LU w CHECK ONE ONLY i <br /> ❑ UNDETERMINED ❑ SOiL ONLY GROUNDWATER ❑ DRINKING WATERT- (CHECKO NLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY !I <br /> I I .s <br /> ❑ NO ACTION TAKEN F__1 PRELIM INARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> j y ❑ LEAK BEING CONFIRMED ® PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U <br /> ❑ <br /> REMEDIATIONPLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY), ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE P RO'DUCT(FP) ❑ ENHANCED BIO DEGRADATK)N(IT) <br /> 4_ mE a a f oetma; .I 1) <br /> 4 ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ BLIMPS TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ® OTHER(OT) Remove all U <br /> _ .st_S—an 1•i n e-s <br /> Z Ethyl Benzene at 2 ppm in SB-2 and 6 ppm Xylene in SB-2, 11 Groundwater in MW-2 indicate <br /> W benzene at 760 ppb, ethyl benzene at 40 ppb, toluene at 50 ppb and xylene at 110 ppb <br /> found during routine property transfer sub-surfacenvestligation. Further assessment <br /> being im lem b <br />