UAR/PROP 65 PRE 2019 - Laserfiche WebLink

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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY ❑ YES ® NO REPORT BEEN FILED? ®YES ❑ NO 1 HEREBY CERTIFY THAT t AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT''I HAVE. REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 251801 OF: REPORT DATEE a THE HEAL AND S Y. kl 6 M 2 5 D 9 Y O YF 115 5 7 SIGNED. DATE NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE Elaine Lavine 1 (415) 571-2482 REPRESENTING ® OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME a ❑ LOCAL AGENCY ❑ OTHER ARCO Products Company W ¢ ADDRESS P.O. Box 5811 Attn: Env. Compl. Dept. San Mateo CA 94402 STREET CTTY STATE ZIP J NAME CONTACTPERSON PHONE z¢ ARCO Products Company ❑ UNKNOWN Elaine Lavine (415) 571-2482 ga ADDRESS LU P.O. Box 5811 Attn: Env.Compl.Dept. San Mateo CA 94402 STREET CITY STATE ZIP FACILITY NAME(IF APPLICABLE) OPERATOR PHONE o ARCO Facility # 6100 Richard Bokides (209) 835-7777 a ADDRESS 25775 S . Patterson Pass Tracy San Joaquin 95376 STREET My COUNTY ZIP CROSS STREET Hwy. 580 a LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE WZ San Joaquin Local Health Lori Cotulla (209) 468-3420 W 3 REGIONAL BOARD PHONE as Central Valley Region Lee Boggs (916) 361-5600 rn (1) NAME QUANTITY LOST(GALLONS) 0 za J Gasoline ® UNKNOWN 2 (2) �' ❑ UNKNOWN DATEDISCOVERED HOWDISCOVERED NUISANCE CONDITIONS w INVENTORY CONTROL ❑ SUBSURFACE MONITORING OM 6M 2D 5D 9v QY ❑ TANK TEST ❑ TANK REMOVAL E' OTHER Borings being drilled n DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) Lil M D D Y Y OX UNKNOWN ❑ REMOVE CONTENTS REPLACE TANK E] CLOSE TANK M >0 HAS DISCHARGE BEEN STOPPED? ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE o ❑ YES [�j NO IF YES,DATE M M D D v Y ❑ OTHER SOURCE OF DISCHARGE CAUSE(S) a ❑ TANK LEAK ® UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL U ❑ PIPING LEAK ❑ OTHER ❑ CORROSION FX-1 UNKNOWN ❑ OTHER WW CHECK ONE ONLY (r a 6�j ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CHECK ONE ONLY LU ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ® POLLUTION CHARACTERIZATION ¢a j y ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY CHECK APPROPRIATE ACTION(S) ® EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) (WE..FM.ETMA w Q ❑ CAP SITE(CD) ® EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) Cr ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) z Product tank to be replaced. Contaminated soil to be excavated. Site 2 assessment to be performed. OES & San Joaquin Health notified. 8 HSC 05(11/89)