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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FORCAL AGENCY USE ONLY <br /> REPORT BEEN FILED 7 <br /> E:]YES NO YES r;,i NO 1 HER YC ERT IFY <br /> CERTIFY TH T I;AM DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> A� REPOR THIS INF M TIOIC 0 LOCAL OFFICIALS PURSUANT TO:SE TION t80.7 OF <br /> REPORT DATE THEAL ADS EM 2 M Y � �CASE# <br /> SIGNEDE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNA R <br /> Diane 1:',. Hinson (209 ) 468-3441 '+ <br /> w REPRESENTING 4, <br /> w 0 OWNER�OPERATOR � REGIONAL BOARD COMPANY OR AGENCY NAME <br /> pP4LOCALAGENCY D OTHERI ,- <br /> San Joaquin Local Heal till District <br /> cc ADDRESS <br /> 16u1 E. hazel ton AVenue Stockton CA 95205 <br /> STREET CITY <br /> m NAME CONTACTPERSON STATE CA <br /> ZIP <br /> Z¢ University of CaliforniaUNKNOWN ;ic.c Henry (415 )423-3641 <br /> as ADDRESS <br /> PO box 808-L-193 STREET LivermoreTATE ivermore CA 94550 <br /> FACILITY NAME(IF APPLICABLE) ZIP <br /> OPERATOR PHONE <br /> o Lawrence Livermore Lau - Site 300 ( ) <br /> a ADDRESS <br /> LIJ STREET Corral Hollow Road Tracy San Joaquin <br /> COUv~-i CROSS STREET 7[ RE <br /> OF AREA a COMMERCIAL INDUSTRIAL ®RURAL TYPEOFBUSINESS�a RETAIL FUEL STATION <br /> SIDENTIAL OTHER FARM Ea OTHERtE'$L1 nd lab <br /> 2 LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> w� San Joaquin Local Health District Diane M. Hinson (209 )458-3441 <br /> w w REGIONAL BOARD <br /> PHONE <br /> 2 Ce,,.tral Valley - segion 5 A. Vorster (916 )361-5600 <br /> (+) <br /> U O NAME QUANTITY LOST(GALLONS) <br /> �> Diesel <br /> F of (2) i® UNKNOWN <br /> `� <br /> N <br /> UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL <br /> w SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> _ <br /> M ' M <br /> 0019 D Z3v J y U TANK TEST TANK REMOVAL OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> j} ® UNKNOWN 0 REMOVE CONTENTS REPLACE TANK CLOSE TANK <br /> M M D D Y Y <br /> HAS DISCHARGE BEEN STOPPED T 0 REPAIR TANK ® REPAIR PIPING CHANGE PROCEDURE <br /> o YES [] NO IF YES,DATEOTHER <br /> M M D D V <br /> SOURCE OF DISCHARGE TANKS ONLYICAPACITY MATERIAL CAUSE(S) <br /> TANK LEAK UNKNOWN d Q�0 GAL. O FIBERGLASS OVERFILL RUPTURE/FAILURE <br /> Cr <br /> PIPING LEAK AGE YRS STEEL CORROSION UNKNOWN <br /> OTHER �� UNKNOWN O OTHER O SPILL O OTHER <br /> w w CHECK ONE ONLY <br /> a <br /> v UNDETERMINED SOIL ONLY GROUNDWATER [::] DRINKING WATER• (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> L� <br /> cr <br /> a SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) 0 CLEANUP IN PROGRESS SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> U h 0 NO ACTION TAKEN E�] POST CLEANUP MONITORING IN PROGRESS 0 NO FUNDS AVAILABLE TO PROCEED 0 EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTIONS)(SEE BACK FOR DETAILS) <br /> 0 z CAP SITE(CD) EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(IT) <br /> w <br /> CONTAINMENT BARRIER(CB) EDEXCAVATE d TREAT(ET) PUMP&TREAT GROUNDWATER(GT) E:] REPLACE SUPPLY(RS) <br /> E:1 TREATMENT AT HOOKUP(HU) NO ACTION REQUIRED(NA) 0 OTHER(OT) <br /> y doti fi cati on is being i.Iade at this tine due to reporting requi renients of S(,1RC3. <br /> w <br /> 8 <br /> MSC 05(4/87) <br />