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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> `IERGENCY hAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENCY USE ONLY <br /> YES NO REPORT BEEN FILED? YES NO I HEREBY CERTIFY THAT t AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 251803 OF <br /> -'+EPORT DATE CASE x THE HEALTH AND SAM CODE <br /> 0 7 2 0 8 9 <br /> A a vi SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNAT RE i <br /> m <br /> Connie DeGrange (+15 ) 422-5167 <br /> _ _ <br /> o REPRESENTING OWNER OPERATOR '� REGIONAL BOARD COMPANY OR AGENCY NAME <br /> cc LOCALAGENCY ! OTHER University of California <br /> 0 — <br /> ADDRESS <br /> P.O. Box 808, L-193 7000 East Avenue Livermore CA 94550 <br /> STREET CITU STATE ZIP <br /> LU NAME CONTACT PERSON PHONE <br /> M <br /> ZQ, Dennis K. Fisher uNKNowN Connie DeGrange (415 ) 422-5167 <br /> R a i ADDRESS <br /> Uj P.O. Box 808, L-193 7000 East Avenue Livermore CA 94550 <br /> STREET CTTV STATE ZIP <br /> FACILITY NAME(IFA pPL CABL OPERATOR PHONE <br /> Building ti0�. Lawrence Livermore <br /> o I National Laboratory Dennis K. Fisher (415 ) 422-8351 <br /> a ADDRESS <br /> Located fifteen miles east of Livermore on Trac San Joaquin <br /> Corral Hollow Road STREET CfTY y COUNTY q P <br /> n CROSS STREET TYPE OF AREA F-7 COMMERCIAL ❑ INDUSTRAL ❑ RURAL TYPE OF BUSINESS F7 RETAIL FUEL STATION <br /> N/A ❑RESIDENTIAL [XOTHER Federal Lab. a FARM OTHER Research <br /> LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> N/A <br /> W ( ) <br /> LU REGIONAL BOARD PHONE <br /> C< Central Valley RWQCB Mike Higgins (916 ) 361-5653 <br /> 0 (1) NAME QUANTITY LOST(GALLONS) <br /> Wo Floor washdown collection system. The most recent analyses 1500 water❑ UNKNOWN <br /> �0 (2)of a representative waste water sample showed 2500ppm oil, 1.5 ppm Freon <br /> U ❑ UNKNOWN <br /> W DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ® SUBSURFACE MONITORING F7NUISANCE CONDITIONS <br /> 0 M 7M 1 , 7 p 8 Y 9 Y ❑ TANK TEST ❑ TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> } <br /> 0 .1 7.1 1 ,,j 7.1 8 yj 9 yj UNKNOWN ® REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> w <br /> HAS DISCHARGE BEEN STOPPED? ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> p ® YES ❑ NO IF YES,DATE 0.1 I 1 01 7 0 8 rl 9 Y ❑ OTHER <br /> SOURCE OF DISCHARGE TANKS ONLYr-APACITY MATERIAL CAUSE(S) <br /> ® TANK LEAK F7 UNKNOWN 4000 GAL. ® FIBERGLASS ❑ OVERFILL ❑ RUPTURIEFAILURE <br /> U PIPING LEAK AGE 9YRS ❑ STEEL7-7 <br /> CORROSION UNKNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL X] OTHER puncture <br /> w w CHECK ONE ONLY <br /> U u UNDETERMINED Xj SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z N <br /> < ® SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> L)N ❑ 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 /> E5 z ❑ CAP SITE(CD) ❑ EXCAVATE 8 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> E5 0Oz <br /> CONTAINMENT BARRIER(CB) ❑ EXCAVATE 6 TREAT(ET) ❑ PUMP 6 TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(FRU) ❑ NO ACTION REQUIRED(NA) ® OTHER(OT) See below <br /> z <br /> The type of remedial action that is necessary is being determined. <br /> W <br /> 8 <br /> NSC 05 l4AM <br />