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NOES UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT EMERGENCY HAS STATE:OFFICE OF EMERGENCY SERVICES FOR OCALMENCY USE ONLY ❑ � REPORT BEEN FILED? ❑YES NO S BY CERTIFY THAT E AM A.DESIGNATEQ OOVERNMENT EMPLOYEE,ANO THAT.k HAVE YES NO R.E O . FLIRMATION TD LOCAL OFF1CfAL$ PUMUMfT TO SECTION 25180:7 OF RE PORT DATETHEN YCOOE 2 0 $Y 8 v CASES SfL3NED DATE NAME OF INDIVIDUAL FILING REPORT PHONE SIGNA D. M. HINSON ( 20*468-3441co 0 REPRESENTING F-1 OWNER/OPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME g (x] LOCALAGFNCY ❑ OTHER SAN JOAQUIN LOCAL HEALTH DISTRICT a ¢ ADDRESS 1601 E. HAZELTON AVE. , STOCKTON CA 95205 STREET CITY STATE ZIP L4 NAME CONTACT PERSON PHDNE z COLBERG INC. El UNKNOWN W.H. COLBERG i09 )466-7041 R a ADDRESS U) cc 401. N. STOCKTOI�,,,STREET �ITYSTOCKTON STATE CA 95203 FACILITY NAME(IFAPPLICABLE) OPERATOR PHONE z COLBERG, INC . COLBERG. INC. p9 }466-7041 0 F' ADDRESS 401 N. STOCKTON STREET STOCKTON , SAN JOAQUIN 95203 STREET CITY COUNTY ZIP y CROSS STREET TYPE OF AREA COMMERCIAL ❑INDUSTRIAL 0 RURAL TYPE OF BUSINESS F-1 RETAIL FUEL STATION FREMONT & LINDSAY ❑RESIDENTIAL F-1 01-HER ❑ FARM � OTHER"HiP YARD LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE Ww SAN JOAQUIN LCOAL HEALTH DIST D M HINSON 209 )468-3441 M REGIONAL BOARD PHONE CENTRAL VALLEY—SACRAMENTO A VORSTER 16 )361-5670 fn (1) NAME QUANTITY LOST(GALLONS) LU� GASOLINE, REGULAR LEADED � UNKNOWN izl y ❑ UNKNOWN z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORYCONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS Lu u M 1 0 6 fl $v �}v l� TANK TEST TANK REMOVAL E::] OTHER DATE DISCHARGE BEGAN ""''''""''gi�p METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) M M o o v y L_._1A UNKNOWN ❑ REMOVEOONTENTS ❑ REPLACE TANK ® CLOSE TANK p HAS DISCHARGE BEEN STOPPED? ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE p w YES ❑ NO IFYES,DATE Q.,l 5 M 1 01 6 01 8yl 6 y ❑ OTHER y SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSES) ❑ TANK LEAK ® UNKNOWN 1000 GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ PIPING LEAK AGE YRS STEEL ❑ CORROSION ® UNKNOWN y 0 OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER yL w CHECK ONE ONLY ® UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER• (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CHECK ONE ONLY Ir e ® SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP iN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) v H ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS 0 NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) ozz ❑ CAP SITE(CD) ❑ EXCAVATE b DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) Q ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) F-1PUMP&TREATGROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) ❑ TREATMENT ATHOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) y h 2 Lu HSC 05 CCU)