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UNDERGROUND STORAGE TANK (UST) SITE- UNAUTHORIZED RELEASE 1 CONTAMINATION REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICESFO RE9YOCCERTIFYGENHATC AM A DESIGNATED Y USE OONLY <br /> DovERrvMENT EMPLOYEE AND THAT I HAVE <br /> ❑Yes NO REPORT BEEN FILED? ❑Yes �NO REPORTED THIS INFORMATION TOL CAL OFFICIALS PURSUANT TO SECTION 25188.7 OF <br /> REPORT DATE CASE# THE HEALTH AND SAFETY ODE. <br /> NA EOF INDIVIDUALFILING REPORT PHONE E SIGNAT / E <br /> Garrett Backus (209 468-2986 j <br /> m REPRESENTING COMPANY OR AGEN AME <br /> LOCALAGENCY ❑REGIONAL BOARD San Joaquin County Environmental Health Department <br /> 0 ❑OWNER/OPERATOR ❑OTHER <br /> ADDRESS <br /> 1868 E Hazelton Ave Stockton CA 95205 <br /> STREET CITY STATE ZIP <br /> j NAME CONTACT PERSON PHONE <br /> y Louis Levand Trust ❑Unknown Paula Levand (661) 904-2133 <br /> z <br /> a� ADDRESS <br /> y 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 /> 0 <br /> r ADDRESS <br /> 3 E l lU' Street Tracy San Joaquin 95376 <br /> yi STREET CITY COUNTY ZIP <br /> m CROSSSTREET <br /> Holly Drive <br /> LOCALAGENCY AGENCY NAME PHONE _ <br /> z H San Joaquin County Environmental Health Department (209) 468-3420 <br /> u REGIONAL BOARD PHONE <br /> x` Central Valley Regional Water Quality Control Board (916) 464-4834 <br /> (�) NAME QUANTITY LOST(GALLONS) <br /> Fuel Ounknom <br /> (2) <br /> N- Automotive Fluids <br /> Unknown <br /> �i DATE DISCOVERED HOW DISCOVERED [ITank Test Tank Removal I-1 Nuisance Conditions <br /> October 14, 2013 El inventory Control ❑Subsurface Monitoring Other <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> r <br /> emove Contents Close Tank <br /> w Unknown ❑Repair Tank ❑ Change Procedure <br /> 0 HAS DISCHARGE BEEN STOPPED? - E] Replace Tank ❑Other <br /> o Yes ❑ No IF YES,DATE May 1, 2014 ❑ Repair Piping <br /> SOURCE OF DISCHARGE CAUSES) <br /> Uy <br /> �aTank [I Piping [I Dispenser ❑Delivery Problem [I Spill L1Over011 [IPhysical/Mechanical Damage [3 Corrosion❑Submersible Turbine Pump(STP) ❑Other ❑Installation Problem Unknown ❑Other <br /> ww CHECK ONE ONLY <br /> Npp <br /> v F Undetermined ❑Soil Only ❑Groundwater [I Drinking Water—(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w <br /> A@ Open-Site Assessment ❑Open-Verification Monitoring <br /> X [I Open-Assessment N <br /> [I Open-Remed anonClosed&Interim Remedial Action CONOInactive <br /> Further-RemedlationFurther Actlon Required <br /> z CHECK APPROPRIATE ACTION(S) <br /> o Human health exposure control? ❑Yes ❑No Unknown <br /> aGroundwater migration control? Yes ❑No ❑Unknown <br /> o ❑No Action Required(NAR) ❑Excavate&Treat(ET) ❑Treatment at Hookup(fH) ❑Other <br /> w ❑Excavate&Dispose(ED) ❑Free Product Removal(FPR) ❑Replace Supply(RS) <br /> w <br /> K <br /> i /If <br /> U <br /> SWRCR Leak Report Form http://www.swrcb.ca.gov/water_issues/programs/ust/forms/ Rev.02/01/2012 <br />