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t ^ <br /> rRGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED? ) REBY CERTIFY H T I H DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> YES ® NO YES NO <br /> AIS IBUT GN SHE INSTRUCTION SHEET ON THE BACK PAG Of T4S FORM <br /> REPORT DATE CASES <br /> e v <br /> 0 M1 8 .10 3 9 4 vSIGNED DATE; <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGN RE . <br /> C. Susi Jackson (510 ) 423-6577 <br /> LLIoCOMPANY OR AGENCY NAME <br /> REPRESENTING © OWNER/OPERATOR ❑ REGIONAL BOARD <br /> p LOCALAGENCY OTHER Universityof California <br /> ir ADDRESS <br /> P.O. Box 808, L-633 STREET 7000 East Ave. Dm Livermore STATE CA 94550 <br /> LU NAME CONTACTPERSON PHONE <br /> z Dennis K. Fisher [:] UNKNOWN C. Susi Jackson (510 ) 423-6577 <br /> Q0 a ADDRESS <br /> LU <br /> cc P.O. Box 808, L-633 STREET 7000 East Ave. CITY LivermoreSTATE CA 9ZIP <br /> 4550 <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> Lawrence Livermore National laboratory <br /> o Site 300 Building 834 Dennis K. Fisher (510 ) 422-3343 <br /> ADDRESS <br /> ° Corral Hollow Road STREET CR South of Tracy C SUNTY an Joaquin ZIP <br /> W <br /> y CROSS STREET <br /> Interstate 580 <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> oLzuSan Joaquin County Public Health Services William Snavely (209 ) 468-0336 <br /> w w REGIONAL BOARD PHONE <br /> :< Central Valley RWQCB Susan Timm (916 ) 255-3057 <br /> y (1) NAME QUANTITY LOST(GALLONS) <br /> a <br /> J Diesel Fuel UNKNOWN <br /> m <br /> o (2) <br /> z_ <br /> U) a UNKNOWN <br /> I.- <br /> DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL E] SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> wTANK TEST ® TANK REMOVAL ® OTHER Smell of diesel fuel in soil <br /> 0 MI 7 MI 2 DI 7 DI 9 Y 4 Y <br /> < DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> m <br /> a <br /> 5z E] UNKNOWN REMOVE CONTENTS ®CLOSE TANK&REMOVE REPAIR PIPING <br /> w Y M D D Y Y <br /> 0 HAS DISCHARGE BEEN STOPPED? Tank Pumped ❑REPAIR TANK CLOSE TANK&FILL IN PLACE a CHANGE PROCEDURE <br /> a ® YES � NO IF YES,DATE OmI 7 u 2 DI 1 D 9 vl 4 v �REPLACE TANK 0 OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> 0 a TANK LEAK UNKNOWN a OVERFILL RUPTURE/FAILURE SPILL <br /> Cn v PIPING LEAK ® OTHER CORROSION a UNKNOWN 0 OTHER <br /> w 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 /> W <br /> NO ACTION TAKEN F7PRELMINARY SITE ASSESSMENT WORKPLAN SUBMITTED 0 POLLUTION CHARACTERIZATION <br /> fr <br /> LEAK BEING CONFIRMED © PREL34INARY SITE ASSESSMENT UNDERWAY 0 POST CLEANUP MONITORING IN PROGRESS <br /> U F7 REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY \ <br /> CHECK APPROPRIATE ACTION(S) C EXCAVATE&DISPOSE(ED) F7 REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(IT) C <br /> J (SFE SACK KA DEfALS) <br /> o zz 7 CAP SITE(CD) C EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> wLU <br /> a F7 CONTAINMENT BARRIER(CB) C NO ACTION REQUIRED(NA) El TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> 2 VACUUM EXTRACT(VE) OTHER(OT) Remove tank & overexcavate <br /> ExcavATION SMELLED OF DIESEL FUEL. SUSPENDED IMPACTED SOIL WAS EXCAVATED AND SAMPLED. <br /> E DIESEL FUEL ALSO IDENTIFIED IN GROUNDWATER FROM NEARBY DOWNGRADIENT WELL MONITORING <br /> o AN 18 FOOT DEEP PERCHED AQUIFER. TANK TESTING HAD SHOWN THIS TANK TO BE LEAK <br /> U <br /> HSC 05(MO) <br />