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amok <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENCY USE ONLY <br /> ❑ YES ❑ NO REPORT BEEN FILED? YES ❑ NO i<HERE$Y CERTIFY THAT t AM A pES1GNAT!D GOVERNMENT EMPLOYEE AND THAT:1 HAVE <br /> .REPORTED THIS.INFORMATION TO k.00AL OFFICIALS PURSUANT TO SECTION 25180,7 OF''. <br /> REPORT DATE F# THE HEALTH AND SAF7Y CODE <br /> O M 7 M 2 p O p 8 y 9 y SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNAT RE <br /> Connie DeGrange x+15 ) 422-5167 <br /> co <br /> o REPRESENTING F-X1 OWNER/OPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME <br /> 0 LOCALAGENCY OTHER University of California <br /> a <br /> ADDRESS <br /> P.O. Box 808, L-193 7000 East Avenue Livermore CA 94550 <br /> STREET CITY STATE ZIP <br /> Lq NAMECONTACT PERSON PHONE <br /> z� Dennis K. Fisher ❑ UNKNOWN Connie DeGrange (415 ) 422-5167 <br /> Cc <br /> R a ADDRESS <br /> P.O. Box 808, L-193 7000 East Avenue Livermore CA 94550 <br /> STREET CTTY STATE ZIP <br /> FACILITY NAME(IFApPL CABLE) OPERATOR PHONE <br /> Building 951 - Lawrence Livermore <br /> o National Laboratory Dennis K. Fisher (415 ) 422-8351 <br /> a ADDRESS <br /> Located fifteen miles east of Livermore on <br /> Corral Hollow Road STREET CITY Tracy COUNn�,Joaquin zip <br /> NCROSS STREET TYPE OF AREA ❑COMMERCIAL ❑ INDUSTRIAL ❑RURAL TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> N/A ❑RESIDENTIAL EMOTHER Federal Lab. FARM ® OTHER Research <br /> LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> LU N/A ( ) <br /> P:w <br /> W Uj REGIONAL BOARD PHONE <br /> Central Valley RWQCB Mike Higgins (916 ) 361-5653 <br /> (1) NAME QUANTITY LOST(GALLONS) <br /> LUO Floor washdown collection system. The most recent analyses 1500 water UNKNOWN <br /> �-o (2)of a representative waste water sample showed 2500ppm oil, 1.5 ppm Freon <br /> Z) ❑ UNKNOWN <br /> Z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ® SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> O M 7 M 1 p 7,)l 8 y 9 y ❑ TANK TEST ❑ TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> OM 7M 1 , 7p 8Y9 Y ❑ <br /> UNKNOWN ® REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> p HAS DISCHARGE BEEN STOPPED? E REPAIR TANK Ej REPAIR PIPING El CHANGE PROCEDURE <br /> oYES ❑ NO IF YES,DATE 0.1 M 1.1 7 p 8 Y 9 Y ❑ OTHER <br /> W <br /> SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> U ® TANK LEAK ❑ UNKNOWN 4000 GAL. © FIBERGLASS ❑ OVERFILL ❑ RUPTURE FAILURE <br /> ❑ PIPING LEAK AGE 9 YRS ❑ STEEL ❑ CORROSION ❑ UNKNOWN <br /> ❑ OTHER O UNKNOWN ❑ OTHER ❑ SPILL © OTHER puncture <br /> w w CHECK ONE ONLY <br /> U ❑ UNDETERMINED SOIL ONLY GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> r CHECK ONE ONLY <br /> zN <br /> a ® SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) F—] CLEANUP IN PROGRESS SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> L)ti ❑ 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 /> z ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> 00 <br /> w ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> cc ❑ TREATMENT ATHOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑X OTHER(OT) See below <br /> r The type of remedial action that is necessary is being determined. <br /> z <br /> 8 <br /> HSC 05(W <br />