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UNDERGROUND STORAGE TAX UNAUTHORIZED RELEASE (LEAK)/t, 04TAMINATION SITE REPORT <br /> EMERGENCYSTATE TANK ID P z- - - <br /> HAS STATE OFFICE OF EME <br /> ❑ �YES NO REPORT BEEN FILED? E] Y ES CRI <br /> ®VNCOES O 010 10 <br /> O O 15 18 19 I I I O 10 12 1 <br /> <_ _ <br /> REPORT DATE LOCAL CASE # REGIONAL BOARD CASE n US EPA ID n -_ <br /> OM %1 21319 018 Y _6 Y 004:515633� <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIG TURE -- <br /> Ronald Quick. (209 > 858-5151 OU16 - <br /> O Uj REPRESENTING ❑ LOCAL AGENCY ❑ OTHER COMPANY OR AGENCY NAM - <br /> O ® OWNER/OPERATOR ❑ REGIONAL BOARD LIBBEY OWENS FORD COMPANY - <br /> a ADDRESS <br /> 500 STREET EAST LOUISE AS � <br /> E CITY ll�r nT� STATE CALIF. z,X338 <br /> , > NAME CONTACT PERSON PHONE <br /> zQ LIBBEY OWENS FORD COMPANY ❑ UNKNOWN <br /> oRONALD QUICK ( 209 ) 858-5151 <br /> a <br /> w w ADDRESS <br /> W m 500 STREET EAST LOUISE AVENUE CITY LATHROP STATE CALIF'. Z,,95330 <br /> FACILITY NAME (IF APPLICABLE) ERATOR PHONE <br /> oOP <br /> LIBBEY OWENS FORD COMPANY JAMES A. MEYER ( 209 ) 858-5151 <br /> ADDRESS <br /> U SAN <br /> ° S00 STREET EAST LOUISE AVENUE CITY LATHROP COUNTY JOA UIN zl®53301 <br /> w CROSS STREET TYPE OF AREA Q COMMERCIAL ®INDUSTRIAL TYPE OF BUSINESS ❑ RETAIL FUEL STAT ION 1 <br /> RESIDENTIAL [-]RURAL ❑OTHER ❑UNKNOWN FIOTHERGa. <br /> 1SS mnfCtS. <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> = San Joaquin County L. H. D. Laurie Contulla ( 209 )466-6781 <br /> w <br /> Z!� REGIONAL BOARD <br /> WW C. R.W.Q.C.B. Central Valley Region Antonia Vorrester ( 916 )445-0270 <br /> d< TSCD <br /> Dept. of Health Services Charles A. McLaughlin ( 916 ) 322-2337 <br /> w CAS 3 (ATTACH EXTRA SHEET IF NEEDED) NAME QUANTITY LOST (GALLONS) <br /> UO <br /> a w> (1) SEE ATTACHED --Kj UNKNOWN <br /> I-J <br /> 00 <br /> M> <br /> �= (2) n UNKNOWN, <br /> DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING <br /> ¢Z QM gM �D D 8 Y Y ❑ ROUTINE MONITORING REMOVAL TANK ❑ NUISANCE CONDITIONS r] OTHER: <br /> ww DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br /> >2 <br /> OUF M Mi 01 01 Y" YI ® UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK ®CLOSE TANK ' <br /> E m HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK ❑REPAIR PIPING ❑CHANGE PROCEDURES <br /> a <br /> YES NO IF YES, DATE 1 O MI 9 MI 0 D12 o18Y16y ❑OTHER <br /> wSOURCE(S) OF DISCHARGE TANKS ONLY/CAPACITY syn GAL CAUSE(S) <br /> > ❑TANK LEAK UNKNOWN 11 4 ❑OVERFILL QCORROSION <br /> a AGE W YRS. ❑ UNKNOWN <br /> U <br /> IIIU ❑PIPING LEAK MATERIAL ❑RUPTURE/FAILURE _]SPILL <br /> ¢ ®STEEL ❑FIBERGLASS <br /> 0 <br /> OTHER (SPECIFY) ❑OTHER ®UNKNOWN ❑OTHER <br /> RESOURCES AFFECTED WATER SUPPLIES AFFECTED THREAT- - <br /> YES NO THREATENED UNKNOWN it z5r— <br /> YES NO ENED KNOWN WELLS <br /> H AIR (VAPOR) ❑ PUBLIC DRINKING ❑ ❑ <br /> W <br /> SOIL (VADOSE ZONE) ❑ ❑ WATER <br /> 10 PRIVATE DRINKING ❑ ❑ ❑ rX'i <br /> ' GROUNDWATER <br /> Y ❑ ❑ �� ® WATER IJ <br /> t <br /> WR SURFACE WATER OR STORM DRAIN ❑ ❑ ❑ ® INDUSTRIAL ❑ ❑ ❑ <br /> ¢F BUILDING OR UTILITY VAULT ❑ ❑ ❑ ® AGRICULTURAL ❑ ❑ ❑ <br /> �� OTHER (SPECIFY) Ej ❑ ❑ OTHER(SPECIFY) a ❑ a <br /> FXIw <br /> GROUNDWATER BASIN NAME <br /> UNKNOWN <br /> COMMENTS: This tank was in the process of being closed as per the U.G.S.T. regulations <br /> Z and it was not in service at the time of removal. Mr. Dan Moers of the S.J.C.L.H.D. <br /> w was present and his inspection report states that the tank was properly dry iced, <br /> 0 appeared in tact and the soil had a strong odor of petroleum products. <br /> COMPLETE AND ATTACH A CLEANUP TRACKING REPORT IF ANY CLEANUP WORK OR PLANNING HAS STARTED ,fsc 05 (10/96) <br />