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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCYSERVICES <br /> FOR LOCAL AGENCY USE ONLY is <br /> ❑ YES � REPORT BEEN FILED 7 ❑;YES ® NO 1 HEREBY CEPTIFY THAT I AM A tlESIONATED UOVERNMENr EMPLOYEE AND THAT-I HAVE--: <br /> REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUAM TO SECTION 25180.7 OF: <br /> REPORTDATE CASE# - IHENEALTHANO SAFTN CODE <br /> O.1 4 Ml 1 3 9 yj Oy swKEo, aTE I <br /> NAME OF INDIVIDUAL FILING REPORT . PHONE 1-800-451— SIGNATU <br /> DANIEL T. KIRK ( )2799-134 �( <br /> m <br /> REPRESENTING ® OWNEWOPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME <br /> p ❑ LOCAL AGENCY ❑ OTHER SHELL OIL COMPANY <br /> a <br /> ¢ ADDRESS , <br /> 1390 WILLOW PASS ROAD STE. 900 CONCORD CA. <br /> STREET CITY SLATE IN <br /> NAME CONTACTPERSON PHONE <br /> SHELL OIL COMPANY l 800-451— <br /> 1 <br /> E] UNKNOWN DIANE LUNDQUIST ( )2799-127 <br /> y ADDRESS <br /> Q SAME AS ABOVE OR P.Oe,JOX 4023 CONORD nv <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> SHELL STATION ROBERT LUTZ <br /> � (Z09 ) 943-1311 <br /> k; ADDRESS <br /> 2320 N. EL DORADO Slw,, WOCKTON SMWWAQUIN P <br /> —y CROSS STREET TYPE OF AREA ®COMMERCIAL❑INDUSTRIAL❑RURAL TYPEOFBUSINESS ® RETAILFUELSTATION <br /> ADAMS ST, ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> tt" 9 LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> 1' zw SAN JOAQUIN CO. ENVIROMENTAL HEALTH KASEY FOLEY ( 209) 468-3420 <br /> u, <br /> REGIONAL BOARD PHONE <br /> a <br /> l a CENTRAL VALLEY ( ) <br /> t y 111 NAME OUANTITY LOST(GALLONS) <br /> SUSPECT WEATHERED GASOLINE ® UNKNOWN <br /> (2) <br /> - ❑ UNKNOWN <br /> i GATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br />�,. <br /> 0 .1 4M1 0 D 5 DI 2 YJ Q y ❑ TANKTEST ❑ TANK REMOVAL Q OTHER SOIL BORING <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THATAPPLY) <br /> M M D D Y y ❑ UNKNOWN ❑ REMOVECONTENTS. ❑ REPLACE TANK ❑ CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED? ❑ REPAIRTANK ❑ REPAIR PIPING ❑ CHANGEPROCEDURE <br /> 5 ❑ YES ❑ NO IFYES,DATE - E—] OTHERM M D D �Y Y <br /> N SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> q <br /> E::] TANK LEAK O UNKNOWN 7-8 M 1-1 OM GAL. ❑ FIBERGLASS ❑ OVERFILL O RUPTURSFAILURE <br /> 1.. ¢ ❑ PIPING LEAK AGE X22 YRS STEEL ❑ CORROSION O UNKNOWN <br /> �. ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER .. <br /> w� CHECKONEONLY - .. <br /> ❑ UNDETERMINED ® SOILONLY E] GROUNDWATER ❑ DRINKING WATER (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY <br /> iw <br /> j, ¢a ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS E) SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> �'A ❑ NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ® EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) .. <br /> ;1z ❑ CAPSITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENMANCEDBIODEGRADATION(IT) <br /> oo <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ETI ❑ PUMP&TREATGROUNDWATER(GT) ❑ REPLACE SUPPLY(AS) <br /> ❑ TREATMENT ATHOOKUP(HU) ❑ NO ACTION REQUIRED INA) ® OT ER(o1) TO BE DETERMINED <br /> v PERMITTING IN PROGRESS TO REPLACE TANKS. NEW TANKS WILL BE PLACED INALTERNATE <br /> 1 LOCATION. <br /> Hsco5luER <br /> k <br />