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UNDERGROUND STORAGE TANK (UST) SITE - UNAUTHORIZED RELEASE I CONTAMINATION 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 PURSUA T TO Sf CTIIOON 25180.7 OF <br /> REPORT DATE CASE # THE HEALT— H DSAF �' Ll qI <br /> April 3, 2013 <br /> SI ED I MTE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATU <br /> Raymond von Flue (209) 468-9848 r <br /> REPRESENTING COMPANY OR AGENCY KAME <br /> ® LOCAL AGENCY F-1 REGIONAL BOARD San Joaquin County Environmental Health Department <br /> ❑ OWNER/OPERATOR ❑ OTHER <br /> ADDRESS <br /> 1868 E. Hazelton Ave. Stockton CA 95205 <br /> STREET GUY STATE ZIP <br /> NAME CONTACTPERSON PHONE <br /> y San Joaquin County ❑ Unknown Kerry Wasson 209) 953-7803 <br /> o ¢ ADDRESS <br /> N a 44 N. San Joaquin St. Stockton CA 95202 <br /> STREET CITY STATE ZIP <br /> FACILITY NAME (IF APPLICABLE) OPERATOR PHONE <br /> o San Joaquin County Records Center Kerry Wasson (209) 953 -7803 <br /> ADDRESS <br /> o 630 N. California St, Stockton San Joaquin 95202 <br /> STREET CITY COUNTY ZIP <br /> CROSS STREET <br /> Oak St, <br /> LOCALAGENCY AGENCYNAME PHONE <br /> c� <br /> w San Joaquin County Environmental Health Dept. — Local Oversight Program (209) 468-0343 <br /> w w REGIONAL BOARD PHONE <br /> ¢ Central Valley Regional Water Quality Control Board (916) 4644834 <br /> (1) NAME QUANTITY LOST (GALLONS) <br /> W O Toluene, Xylenes, Total Ethylbenzene ® Unknown <br /> P <br /> n (Z) <br /> Total Petroleum Hydrocarbons (TPH) Gasoline ® Unknown <br /> DATE DISCOVERED HOW DISCOVERED <br /> Tank Test Tank Removal ❑ Nuisance Conditions <br /> 03/12/2012 ❑ Inventory Control ❑ Subsurface Monitonng Other <br /> ¢ DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br /> � <br /> 11 Remove Contents ® Close Tank. <br /> ® Unknown ❑ Repair Tank ❑ Change Procedure <br /> o HAS DISCHARGE BEEN STOPPED? ❑ Replace Tank ❑ Other <br /> ® Yes ❑ No IF YES, DATE March 29, 2012 ❑ Repair Piping <br /> w SOURCE OF DISCHARGE CAUSE(S) <br /> ¢ ❑ Tank 11 Piping ❑ Dispenser El Delivery Problem ❑ Spill ❑ Overfill ❑ Physical/Mechanical Damage ❑ Corrosion <br /> vii " ❑ Submersible Turbine Pump (STP) ® Other ❑ Installation Problem ® Unknown ❑ Other <br /> CHECK ONE ONLY <br /> ® Undetermined ❑ Soil Only ❑ Groundwater ❑ Drinking Water - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w0 ❑ Open - Site Assessment Open - Verification Monitoring <br /> j a ❑ Open - Assessment & Interim Remedial Action ❑ Open - Inactive <br /> ❑ Open - Remediation ❑ Closed - No Further Action Required <br /> CHECK APPROPRIATE ACTION(S) <br /> FHuman health exposure control? El Yes El No ® Unknown <br /> a <br /> Groundwater migration control? ❑ Yes ❑ No ® Unknown <br /> o ❑ No Action Required (NAR) ❑ Excavate & Treat (ET) ❑ Treatment at Hookup (TH) ❑ Other <br /> ❑ Excavate & Dispose (ED) ❑ Free Product Removal (FPR) ❑ Replace Supply (RS) <br /> This site location is being referred to the Local Oversight Program, <br /> z <br /> 0 <br /> 0 <br /> SWRCB Leak Report Form http://www.swreb.ca.gov/water-issues/programs/ust(forms/ Rev. 02/01/2012 <br />