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UNDERGROUND STORAGE TANK(UST)SITE- UNAUTHORIZED RELEAc,..: 1 CONTAMINATION REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑Yes No REPORT BEEN FILED? ❑Yes _N`No I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> REPORT DATE CASE# THE HEALTH AND SAFETY CODE. <br /> EDATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNAT <br /> Garrett Backus (209) 468-2986z�Zt <br /> o REPRESENTING COMPANY OR AGEN AME <br /> LOCAL AGENCY ❑REGIONAL BOARD San Joaquin County Environmental Health Department <br /> O []'OWNER/OPERATOR ❑OTHER <br /> W ADDRESS <br /> 1868 E Hazelton Ave Stockton CA 95205 <br /> STREET CITY STATE ZIP <br /> „U NAME CONTACT PERSON PHONE <br /> Louis Levand Trust ❑Unknown Paula Levand (661) 904-2133 <br /> 0-aADDRESS <br /> CL <br /> w 24692 Sand Wedge Lane Valencia CA 91355 <br /> STREET CITY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> Levand Property Paula Levand (661) 904-2133 <br /> ADDRESS <br /> 0 3 E l It' Street Tracy San Joaquin 95376 <br /> W STREET CITY COUNTY ZIP <br /> y CROSS STREET <br /> Holly Drive <br /> LOCALAGENCY AGENCY NAME PHONE <br /> c�co <br /> ZSan Joaquin County Environmental Health Department (209) 468-3420 <br /> z w <br /> Z U <br /> Wz <br /> w REGIONAL BOARD PHONE <br /> CL <br /> Central Valley Regional Water Quality Control Board (916) 464-4834 <br /> (1) NAME QUANTITY LOST(GALLONS) <br /> Cn <br /> z w Fuel 'Unknown <br /> Q J <br /> w O (2) <br /> m� <br /> Automotive Fluids unknown <br /> z DATE DISCOVERED HOW DISCOVERED ❑Tank Test , <br /> October 14, 201315 <br /> Tank Removal I--I Nuisance Conditions <br /> W ❑Inventory Control ❑Subsurface Monitoring _ Other <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a Remove Contents -^Close Tank <br /> r <br /> W Unknown ❑Repair Tank ❑ Change Procedure <br /> HAS DISCHARGE BEEN STOPPED? ❑ Replace Tank ❑Other <br /> o Yes ❑ No IF YES,DATE May 1, 2014 ❑ Repair Piping <br /> I w SOURCE OF DISCHARGECAUSE(S) <br /> U <br /> D a Tank [:1 Piping El Dispenser E]Delivery Problem ❑Spill [I Overfill [IPhysical/Mechanical Damage ❑Corrosion <br /> v0i U ❑Submersible Turbine Pump(STP) [IOther ❑Installation Problem Unknown [IOther <br /> W.w CHECK ONE ONLY <br /> !2 IL <br /> 0 ,Undetermined ❑Soil Only ❑Groundwater ❑Drinking Water–(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY <br /> w w .>H Open-Site Assessment ❑Open-Verification Monitoring <br /> ❑Open-Assessment&Interim Remedial Action ❑Open-Inactive <br /> ❑Open-Remediation ❑Closed–No Further Action Required <br /> CHECK APPROPRIATE ACTION(S) <br /> Q Human health exposure control? ❑Yes ❑No�minknown <br /> aGroundwater migration control? Yes ❑No ❑Unknown <br /> < ❑No Action Required(NAR) ❑Excavate&Treat(ET) ❑Treatment at Hookup(TH) ❑Other <br /> 0 <br /> � <br /> ❑Excavate&Dispose(ED) ❑Free Product Removal(FPR) ❑Replace Supply(RS) <br /> W <br /> z <br /> z <br /> w <br /> O <br /> U <br /> SWRCB Leak Report Form http://www.swrcb.ca.gov/water—issues/programs/ust/forms/ Rev.02/01/2012 <br />