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- u3a <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br /> ❑ YES Pq NO REPORT BEEN FILED 9 FOR.LOCALAGENCY USE ONLY <br /> ❑ YES NO 1 HEREBY;CERTIFYTHAT I HAVE DISTRIBUTED THISINFORMATION ACCORDING TO THE <br /> REPORT DATE CASE s DI IBUTION SHOWN ON THE.INSTRUCTION SHEET ON THE BACK PAGE OF:THIS FORM <br /> OP�4*5 1 d 0 d 9 4 <br /> NAME OF INDIVIDUAL FILING REPORT DATE <br /> PHONE SIGNATUR <br /> C>- Lewyn Boler ( 209)9437337 / <br /> w REPRESENTING OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NA <br /> O 1:1 LOCAL AGENCY ❑ OTHER PRODUCTION Chemical M=g. Inc. <br /> s ADDRESS <br /> 1000 STREETEast Channel <br /> w NAME �m Stockton STATE Ca ZIP 5 <br /> JG07NTACT PERSON PHONE <br /> z r- Lewyn Boler UNKNOWN <br /> ry a ADDRESS ❑ e ( 209)963-7337 <br /> W <br /> Cr 1000Ch �+ <br /> STREETEast Channel Street Om Stockton STATcI. <br /> FACILITY NAME(IF APPLICABLE) a ZIP <br /> OPERATOR PHONE <br /> o Production Chemical Mfg. Inc. Same ( 209 ) 943-7337 <br /> ADDRESS <br /> U <br /> Q 1000 San Joaquin <br /> STREET East Channel Street cm Sto n COUNTY zip 952 S <br /> y CROSS STREET <br /> Union <br /> Z LOCAL AGENCY AGENCY NAME CONTACT PERSON <br /> PHONE <br /> W v San Joaquin Public Health Services env' Margaret Lagorio (209 )468-3449 <br /> w a REGIONAL BOARD romental Health PHONE <br /> as <br /> Central Valle ( ) <br /> LU (�) NAME QUANTITY LOST(GALLONS) <br /> a? Gasoling UNKNOWN <br /> Z) <br /> i (2) <br /> U) Kerosene ® UNKNOWN <br /> LU <br /> DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL © SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> r [:] TANK TEST ❑ TANK REMOVAL ❑ OTHER <br /> w 0.1 7 M1 201 9 DI 9 Yj 3 <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w MI M D 01 Yj yj E:1 UNKNOWN REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> p HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK <br /> CLOSE TANK&FILL IN PLACE CHANGE PROCEDURE <br /> U <br /> `n ❑ YES� NO IF YES.DATE MI D� v r REPLACE TANK OTHER <br /> [;] <br /> M� ❑ ❑ <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> a ❑ TANK LEAK ❑X UNKNOWN ❑ OVERFILL ❑ RUPTURFJFAILURE ❑ SPILL <br /> y U ❑ PIPING LEAK Q OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> N <br /> wa CHECK ONE ONLY x \,n <br /> < \' <br /> U - UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER •(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> w ( CHECK ONE ONLY <br /> ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED O POLLUTION CHARACTERIZATION C <br /> cw 0 LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS ( ,1 <br /> U i ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ <br /> (SEE BACK FM OETA�S) EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> J <br /> a ZCAP SITE(CD) <br /> 0 0 ❑ ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWAT—jER�(/G�JT) g�lA[C`�l PLY(RS) <br /> a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) Q TREATMENT AT HOOKU �( t l, \(F)J/7a$pI ) <br /> ® VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> z IqA S`�7' 0>-1–)r e. ri +� MAY 1 11994 <br /> 2 'e tk& T <br /> � <br /> ENVIRONMENTAL <br /> LTN <br /> CES <br /> ct 17& HSC OS(mo) <br />