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�13 <br /> NDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EWERGENCY SERVICES E R LOCAL AGENCY USE ONLY <br /> ❑ YES ® NO REPORT BEEN FILED Z <br /> YES ❑ No 1 H REBY.CERTI A71.H VE DISTRIBUTED THIS INFORMATION ACCORDING T THE <br /> DIE I U-ION SP E INSTRUCTION SHEET ON THE BACK PAGE FTH ORM <br /> REPORT DATE Ty <br /> SE t 22 <br /> 0 M 8 .10 d 2 9 rI SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIG RE <br /> } <br /> m C. Susi Jackson (510 ) 423-6577 <br /> a REPRESENTING ® OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> 2 ❑ LOCAL AGENCY ❑ OTHER University of California <br /> Q ADDRESS <br /> P.O. Box 808 L-633STREET 7000 East Ave. CRY Livermore STATE CA. Z,p455 <br /> W NAME CONTACTPERSON PHONE <br /> J <br /> ZIt Dennis K. Fisher ❑ UNKNOWN C. Susi Jackson � (510 ) 423-6577 <br /> Oa< ADDRESS <br /> Na <br /> LU <br /> P.O. Box 808, L-633 STREET 7000 East Ave. Livermore STATE CA 94550 <br /> ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> Lawrence Livermore National Laboratory <br /> a Site 300 Buildin 871 Dennis K. Fisher (510 ) 422-3343 <br /> a ADDRESS <br /> U <br /> ° Corral Hollow RoadSTREET South of Tracy San Joaquin <br /> LU CITY COUNTY ZIP <br /> ~ CROSS STREET <br /> U) <br /> Interstate 580 <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> z0 <br /> W o San Joaquin County Public Health Services William Snavely (209 ) 468-0336 <br /> w w REGIONAL BOARD U PHONE <br /> J <br /> Central Valley RWQCB Susan Timm (916 ) 255-3057 <br /> w (1) NAME QUANTITY LOST(GALLONS) <br /> z> <br /> Diesel Fuel UNKNOWN <br /> m z (2) <br /> ❑ UNKNOWN <br /> z DATE DISCOVERED HOW D'a�VERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> LU <br /> LU 0 M1 7 ml 2 0�6 0� 9 Y14 r ❑ ANKTEST ® TANK REMOVAL ® OTHER Smell of Diesel fuel in soil <br /> r <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M M o o v r UNKNOWN ❑REMOVE CONTENTS ®CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> p Uj <br /> HAS DISCHARGE BEEN STOPPED 4Tank Pum ed ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> alil <br /> YES ❑ NO IF YES,DATE 0 MI 7 w 2 ,11 p of 9 yj 4 r ❑REPLACE TANK ❑ OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> Uj <br /> a ❑ TANK LEAK ❑ UNKNCNH OVERFILL F7RUPTURE/FAILURE ❑ SPILL <br /> OU)v ❑ PIPING LEAK ❑X OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> N w� CHECK ONE ONLY <br /> U ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) ' <br /> CHECK ONE ONLY <br /> z j ❑ NO ACTION TAKEN ❑ PR=3AINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> ¢� <br /> ❑ LEAK BEING CONFIRMEDE PRE-MINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> v ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) C EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED 810 DEGRADATION(IT) <br /> J (SEE&1GK FOR OETNSj <br /> o zz ❑ CAP SITE(CO) ❑ EXCAVATE 8 TREAT(E� ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> W a 71CONTAINMENT BARRIER(CB) ❑ 'JO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> Cr <br /> ❑ VACUUM EXTRACT(VE) C OTHER(OT) Remove tank & overexcavate <br /> co Sensory evidence suggested dispersed contamination in the bottom of the excavation. <br /> z Suspected impacted soil was excavated and sampled. Tank testing had shown this tank <br /> o to be leak tight. <br /> U <br /> HSC 05 j&90) <br />