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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> 11 <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL GENCY USE ONLY <br /> YES �NO REPORT BEEN FILED? [_] YES [><NO THEREBY CE TIFY THAT 1 AM,A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> REPORTED TH INFORMATI TO AL OFFICIALS PURSUANT TO SE TION 25180.7 OF <br /> REPORT DATE CASE• THE HEALTH AN AFT I D <br /> DI SIGNED <br /> ATE <br /> NAM OF IND <br /> IVIDUAL FILING REPORT PHONE SIGN URE <br /> w REPRESENTING a OWNER/OPERATOR :REGIONAL BOARD COMPANY OR AGENCY NAME <br /> 0. LOCAL AGENCY OTHER <br /> a San Joaquin Local Health District <br /> cc ADDRESS <br /> 1601 STREET /E. Hazelton Stockton CA 95205 <br /> CITY STATE ZIP <br /> LU NAMECONTACT PERSON PHONE <br /> >> <br /> J <br /> Z Q UNKNOWN Maz Nicholson P09 ) 946-4123 <br /> RQa ADDRESS <br /> w <br /> Cr 405STREET ,S. Fresno Avenue �, tockton STAT ECA 952pP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> o Tillie Lewis Plant Ogden Food Products 209) 946-4123 <br /> a ADDRESS <br /> 8 405 S, Fresno Avenue <br /> H STREET ,S.,tockton San Ag�,qui n 9526 <br /> CROSS STREET TYPE OF AREA 0 COMMERCIAL INDUSTRIAL O RURAL TYPE OF BUSINESS <br /> RETAIL FUEL STATION <br /> ashington F-1 RESIDENTIAL OOTHER FARM ® OTHER�ppd �rOcesS <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> wLuan Joaquin Local Health District D. M. Hinson ?09 X68-3441 <br /> MREGIONAL BOARD <br /> PHONE <br /> Central Valley Region-Sacramento A. Vorster 916 )30 -54O-�0 <br /> y (1) NAME QUANTITY LOST(GALLONS) <br /> Ozd w #6 Fuel Oil _ ® UNKNOWN <br /> 0 (2) <br /> N F UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED a INVENTORY CONTROL )ff] SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> LU <br /> Wm 0 .13 .1 O o 9 p1 8 yj 7 y E�:] TANK TEST E:] TANK REMOVAL 0 OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> w M M o o v y UNKNOWN REMOVE CONTENTS REPLACE TANK CLOSE TANK <br /> 0 HAS DISCHARGE BEEN STOPPED? REPAIR TANK REPAIR PIPING CHANGE PROCEDURE <br /> p YES NO IF YES,DATE O M 3M 0 0 9 o 8 v 7 y OTHER <br /> N SOURCE OF DISCHARGE TANKS ONLYICAPACITY MATERIAL CAUSE(S) <br /> TANK LEAK E] UNKNOWN 40,000 GAL. FIBERGLASS OVERFILL F7 RUPTURE/FAILURE <br /> PIPING LEAK AGE YRS STEEL CORROSION � UNKNOWN <br /> 2 OTHER x UNKNOWN OTHER concrete SPILL kA OTHER <br /> UJ w CHECK ONE ONLY <br /> �a <br /> UNDETERMINED SOIL ONLY k GROUNDWATER DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> r CHECK ONE ONLY <br /> LU a X© SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) CLEANUP IN PROGRESS D SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> Cl <br /> L)N NO ACTION TAKEN [:::] POST CLEANUP MONITORING IN PROGRESS NO FUNDS AVAILABLE TO PROCEED EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> <z � CAP SITE(CD) EXCAVATE&DISPOSE(ED) a REMOVE FREE PRODUCT(FP) ENHANCED BIODEGRADATION(IT) <br /> 00 <br /> F-] CONTAINMENT BARRIER(CB) F EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> cc O TREATMENT AT HOOKUP(HU) 0 NO ACTION REQUIRED(NA) O OTHER(OT) <br /> Groundwater contamination documented as a result of site assessment in progress. <br /> z. Fueld oil tank has been emptied and cleaned. <br /> 8 <br /> HSC 05(4B7) <br />