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I <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ YES n NO REPORT BEEN FILED? ❑ YES NO I HEREBY CERTIFY THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT HAVE' <br /> REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> REPORT DATE CASE�► THE HEALTH AND SAFTY CODE <br /> O M q, D Y UAR occurred prior to 1-1-87 <br /> 8v SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE S NATURE <br /> m <br /> Diane M. HInson ( 209 468-3441 + _. <br /> w REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> 0 �LOCALAGENCY OTHER San Joaquin Local Health District <br /> a <br /> ADDRESS <br /> 16 1 r, ,,, E. Hazelton Avenue CITY Stockton STATE A 95 05 <br /> NAME CONTACTPERSON PHONE <br /> Z¢ Roberts Petroleum Services, Inc❑ UNKNOWN Bruce Woolsey (209)334-3967 <br /> R a ADDRESS <br /> P. 0. BOX 347 STREET My Lodi STATE CA ;�241 <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> o Roberts Petroleum Services, Inc. same (209) 334-3967 <br /> ADDRESS <br /> 930 E. Victor Road Lodi San Joa uin 95240 <br /> H STREET CRY ZIP <br /> ZIP <br /> CROSS STREET TYPE OF AREA ❑COMMERCIAL Q INDUSTRIAL O RURAL TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> ❑RESIDENTIAL ❑OTHER a FARM [ (OTHER distributor <br /> 9 LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> Cn <br /> Wu San Joaquin Local Health District Laurie Cotulla (209)468-3423 <br /> w w REGIONAL BOARD PHONE <br /> CL <br /> a` Region Water - Central Valley - Sac. A. Vorster (916)361-5600 <br /> rn (1) NAME QUANTITY LOST(GALLONS) <br /> WO <br /> > Gasoline UNKNOWN <br /> J <br /> N~C (2) <br /> m� <br /> N Diesel UNKNOWN <br /> w DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> MW O M 5 M 1 DO D 8v 5 v ❑ TANK TEST ❑ TANK REMOVAL ® OTHER site rnnstruction <br /> f <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> I M M D D Y Y <br /> [:XXUNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED? ❑ REPAIR TANK El <br /> PIPING ❑ CHANGE PROCEDURE <br /> unknown <br /> p YES ❑ NO IFYES,DATE M M D D y y ® OTHER unknown <br /> � <br /> SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> 6 ❑ TANK LEAK [a UNKNOWN i n,00.0 GAL. a FIBERGLASS a OVERFILL ❑ RUPTURE/FAILURE <br /> PIPING LEAK AGEYRS STEELcc CORROSION ® UNKNOWN <br /> 2 ❑ OTHER ❑ UNKNOWN OTHER abovegrd. ❑ SPILL ❑ OTHER <br /> WW CHECK ONE ONLY <br /> ❑ UNDETERMINED ❑ SOIL ONLY GROUNDWATER ❑ DRINKING WATER• (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY <br /> zU) <br /> 2 a XkR] SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> 0 rn ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 0 z ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> 00 <br /> W <br /> � ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE 8 TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> cc ❑ TREATMENT AT HOOKUP(HU) NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> p <br /> z <br /> z <br /> w <br /> o� <br /> U <br /> HSC 05(0187) <br />