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� - r <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY STATE TANK ID <br /> HAS STATE OFFICE OF EMERGENCY SERVICES <br /> YES [j] NO REPORT BEEN FILED? E] YES NO <br /> REPORT DATE LOCAL CASE It REGIONAL BOARD CASE # US EPA ID# <br /> OMI 9M Op8 Di 8y 6y <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGN TURE <br /> m Beverly Long ( 209 ) 583-3247 <br /> O REPRESENTING 0 LOCAL AGENCY 0 OTHER COMPANY OR AGENCY NAME <br /> w <br /> O ® OWNER/OPERATOR REGIONAL BOARD BEACON OIL COMPANY <br /> a ADDRESS <br /> 525 West Third Street Hanford California 93230 <br /> STREET _ CITY STATE ZIP <br /> I } NAME CONTACT PERSON PHONE <br /> zx Beacon Oil Company UNKNOWN James McCutchen 1(209 ) 583-3206 <br /> Oa <br /> W <br /> aw ADDRESS 525 West Third Street Hanford Call;R-Fpia 93j,1 O <br /> J <br /> ¢m STREET <br /> FACILITY NAME (IF APPLICABLE) OPERATOR Beacon Oil Company PHONE <br /> o Station #502 Manager: Mary Becker ( 209 ) 369-1525 <br /> ~ ADDRESS <br /> U 35 North Cherokee Lane Lodi San Joaquin 95240 <br /> O STREET CITY COUNTY ZIP <br /> J <br /> w CROSS-STREET TYPE OF AREA ® COMMERCIAL O INDUSTRIAL TYPE OF BUSINESS [� RETAIL FUEL STATION <br /> F <br /> N Elm Street RESIDENTIAL 0 RURAL 0 OTHER UNKNOWN 0 OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> Z San Joaquin County Local Health Distric Laurie Cotulla ( 209 ) 466-6781 <br /> Zw REGIONAL BOARD <br /> xZ Central Valley Gordon Boggs ( 916 ) 445-0270 <br /> wW <br /> a¢ TSCD <br /> s <br /> w CAS q (ATTACH EXTRA SHEET IF NEEDED) NAME QUANTITY LOST (GALLONS) <br /> zw Diesel Fuel UNKNOW <br /> F J <br /> nO <br /> Nm> n UNKNOW <br /> - (2) <br /> DATE DISCOVERED HOW DISCOVERED 0 INVENTORY CONTROL E] SUBSURFACE MONITORING <br /> yF- O M 9 M (� Frr 6 Y 0 ROUTINE MONITORING 0TANK REMOVAL 0 NUISANCE CONDITIONS JL ] OTHER: .A.,,-,,..,1 _Testl g <br /> W W DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br /> OUW M M D D Y Y ® UNKNOWN REMOVE CONTENTS REPLACE TANK [:]CLOSE TANK <br /> Om HAS DISCHARGE BEEN STOPPED? ��REPAIR TANK REPAIR PIPING OCHANGE PROCEDURES <br /> [RIQ <br /> YES ONO IF YES, DATE I nMI 9 M D Y y 0OTHER <br /> SOURCE(S) OF DISCHARGE TANKS ONLY/CAPACITY 12,000 GAL CAUSE(S) <br /> '^ 0 TANK LEAK UNKNOWN 2 2 a OVERFILL CORROSION <br /> AGE YRS. ® UNKNOWN <br /> UPIPING LEAK MATERIAL RUPTURE/FAILURE E]SPILL <br /> U ®STEEL FIBERGLASS <br /> ir <br /> O 0 OTHER (SPECIFY) [D OTHER ®UNKNQWN 0 OTHER <br /> THREAT- - <br /> ` RESOURCES AFFECTED YES NO THREATENED UNKNOWN WATER SUPPLIES AFFECTED I�O ENED KNOWN WELLS <br /> F AIR (VAPOR) 0 ba 0 �_� PUBLIC DRINKINGEl -I ED DM <br /> WSOIL (VADOSE ZONE) WATER I_1 <br /> y, � 0 �� � PRIVATE DRINKING <br /> U. <br /> Y' GROUNDWATER 0 0 El WATER <br /> W SURFACE WATER OR STORM DRAIN 0 0 0INDUSTRIAL 0 0 0 <br /> U BUILDING OR UTILITY VAULT 0 O 0 0 AGRICULTURAL O D D <br /> =O� OTHER (SPECIFY) El 0 a 0 OTHER(SPECIFY) 0 C7 D <br /> 0 <br /> w <br /> GROUNDWATER BASIN NAME <br /> 0 UNKNOWN <br /> COMMENTS: <br /> Closure Plan has been submitted for approval and contractor and geologist <br /> z contacted to remove tank and perform soil sampling. <br /> w <br /> f <br /> f <br /> O <br /> U <br /> COMPLETE AND ATTACH A CLEANUP TRACKING REPORT IF ANY CLEANUP WORK OR PLANNING HAS STARTED Esc 05 (10/85) <br />