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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE <br /> RFPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> Z Yes ❑ No REPORT BEEN FILED? Z 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 /> 10/02/2012 Cal EMA#12-5928 <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> D. Chris Weber (310) 371-1492 6ww- <br /> ca <br /> LU REPRESENTING COMPANY OR AGENCY NAME <br /> o <br /> El LOCAL AGENCY [I REGIONAL BOARD BP West Coast Products LLC <br /> w Z OWNER/OPERATOR ❑ OTHER <br /> ADDRESS <br /> P.O. Box 6038 Artesia CA 90702 <br /> STREET CITY STATE ZIP <br /> wNAME CONTACT PERSON PHONE <br /> N> Khai Vo El Unknown (209)941-2694 <br /> Z 0: ADDRESS <br /> oQ <br /> Ua <br /> w <br /> STREET CITY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> Z ARCO #2186 209) 941-2694 <br /> a ADDRESS <br /> 3212 N California Stockton San Joaquin 95204 <br /> w STREET CITY COUNTY ZIP <br /> CROSS STREET <br /> LOCAL AGENCY AGENCY NAME PHONE <br /> ZW <br /> Z z San Joaquin CountyEnvironmental Health Department (209) 468-3420 <br /> J REGIONAL BOARD PHONE <br /> Central Valley Region (5) (916) 341-5851 <br /> LU (�) NAME QUANTITY LOST(GALLONS) <br /> > Gasoline 87 Octane 0.5 Gallons ❑ Unknown <br /> �o <br /> U)_z (Z) <br /> W ch ❑ Unknown <br /> Z DATE DISCOVERED HOW DISCOVERED ❑Tank Test Tank Removal ❑Nuisance Conditions <br /> w 10/01/2012 <br /> LU ❑Inventory Control ❑Subsurface Monitoring ®Other <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M <br /> a10/01/2012 E]Remove Contents ❑ Close Tank <br /> r <br /> X ❑ UNKNOWN ❑Repair Tank ❑ Change Procedure <br /> o HAS DISCHARGE BEEN STOPPED? ❑ Replace Tank ®Other-Absorbent <br /> U <br /> o ®YES ❑ NO IF YES,DATE 10/01/2012 ❑ Repair Piping <br /> w SOURCE OF DISCHARGE CAUSE(S) <br /> D <br /> < El Tank Leak [:1 Piping Leak El Unknown Z Other [j Overfill [:1 Corrosion E:1Rupture/Failure El Unknown El Spill Z Other— <br /> Cn Customer Top Off <br /> W w CHECK ONE ONLY <br /> Z Undetermined ❑Soil Only ❑ Groundwater ❑ Drinking Water—(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> El No Action Taken Z Case Closed(Cleanup Completed or Unnecessary) <br /> Ua ❑ Leak Being Confirmed ❑ Pollution Characterization <br /> ON <br /> ❑ Remediation Plan ❑ Post Cleanup Monitoring in Progress <br /> ❑ Preliminary Site Assessment Workplan Submitted ❑Cleanup Underway <br /> ❑ Preliminary Site Assessment Underway <br /> CHECK APPROPRIATE ACTION(S) <br /> a Z ❑Cap Site(CD) ❑Excavate&Treat(ET) ❑Treatment At Hookup(HU) Z Other <br /> 00 <br /> W P- El Contamination Barrier(CB) El No Action Required(NA) [:1 Enhanced Bio Degradation(IT) <br /> W a ❑Vacuum Extract(VE) El Remove Free Product(FP) El Replace Supply(RS) <br /> ❑ Excavate&Dispose(ED) ❑ Pump&Treat Groundwater GT ❑Vent Soil(VS) <br /> Z A customer was fueling on Pump#5 and overfilled their fuel tank, causing a fuel spill of <br /> o approximately 0.5 gallons that was contained and cleaned up by the site operator with 0.5 bags of <br /> absorbent. The absorbent was disposed of in the solid hazardous waste drum located on-site. <br /> � <br /> UN-028-2/3 ww unidocs.org � O l n1O/�y„"''_ ev.10/ U06 <br />