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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK) CONTAMINA ON SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br /> ❑ YES M NO REPORT BEEN FILED 9 TOR LOCAL AGENCY USE ONLY <br /> ED YES �] NO j HEREBY <br /> IFYTWI WA DISTRlOUTED TH15 WFORM11T10F1 AOCORDING TO TH <br /> ISTE: <br /> REPORT DATE CASE s OAIBU.T(ON SHOWN ON THE MISTRUUM SHEET ON THE BACK PAGE OF,THIS FORM <br /> Y SIGNED <br /> NAME OF INDIVIDUAL FILING REPORT `" PATE <br /> 7PHONE SIGN RE <br /> ca <br /> Dina Abate X205 468-3468 <br /> p REPRESENTING <br /> El OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> Uj R ® LOCAL AGENCY OTHER San Joaquin county Environmental Health <br /> Cr ADDRESS <br /> 304 E. Weber AVE #3 Floor <br /> EET to Stockton CA 95202 <br /> STR <br /> w NAME CffySTATE ZIP <br /> The Record CONTACT PERSON <br /> PHONE <br /> Z ❑00 UNKNOWN Jim Franco 209 943-8550 <br /> 05 A RESS <br /> w <br /> ac <br /> %V11 wSTREET <br /> FACILITY NAME(IF APPLICABLE) STATE P <br /> OPERATOR PHONE <br /> � The Record � � <br /> < ADDRESS <br /> 530 E. Market STREET Stockton <br /> m <br /> CRSS STREET CITYStocktonS.J. ,9520 <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> LU <br /> Wountyroxnaintal / <br /> Lu L REGIONAL BOAR `PHONE / <br /> 2 Central Valley Jim Barton (916 )255-3115 <br /> y NAME QUANTITY LOST(GALLONS) <br /> > gasoline <br /> UNKNOWN <br /> (2) <br /> N <br /> a UNKNOWN <br /> i GATE DISCOVERED HOW DISCOVERED f--j INVENTORY CONTROLSUBSURFACE MONITORING NUISANCE CONDITIONS <br /> w ❑ <br /> � TANK TEST TANK REMOVAL ❑ OTHER <br /> D Y Y <br /> i DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M1 d 01 yl r 15� UNKNOWN ❑REMOVE CONTENTS CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED 1 REPAIR TANK CLOSE TANK&FILL IN PLACE <br /> 8 ❑ ❑ ❑CHANGE PROCEDURE <br /> p ® YES ❑ NO IF YES,DATE Q 1 1 D 4 j 0 y13 Y ❑REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ❑ TANK LEAK ® UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> !u+Lul ONE ONLY <br /> c13 UNDETERMINED ❑ SOIL ONLY GROUNDWATER E] DRINKING WATER-(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> �Z NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECKAPPROPRIATE OCTAadl ACTION(S) <br /> ran atT ❑ EXCAVATE E DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP MU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> W �es�ens 6!� 1° ry 1/ �� rGc�e,J -itr n aes-6j.0-fe- •r -% QL <br /> e. La. S r c e o A.-(A OA i AAA or it <br /> 0^v t no 1%rno-..-/ t��►.J <br /> Lo c.4 0 tri sc k{- <br /> HSC 05Ia" <br />