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UNDERGROUND STORAGE TAM UNAUTHO131 4"' <br /> LEASE(LEAK)/CENTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICtOF EMERGENCY.SEg <br /> OR LOCAL-AGENCY USE ONLY <br /> REPORT BEEN FILED 7 <br /> O YES NO YES [ EREHYCERTIFYTHATI HAVE DISTRIBUTEDTHISINFb4MATMAC(bRD.imREPORT DATE IBUTfONSHOWN ON THE INSTRUCTION SHEE7ON THE SACK PAGEOF:THIS FORMCASEa <br /> OM 8M 29 6 <br /> DA <br /> NM <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNA <br /> BRETT HOVLAND ( 51g 675-6149 <br /> w REPRESENTING a OWNER/OPERATOR REGIONAL BOARD COMPANY OR AGENCY NAME <br /> S LOCAL AGENCY F-] OTHER SHELL OIL PRODUCTS <br /> w <br /> ADDRESS <br /> P.O. BOX 4023 CONCORD CA 94524 <br /> STREET CITY STATE ZIP <br /> J NAME CONTACT PERSON PHONE <br /> z� SHELL OIL PRODUCTS , CO. DUNKNOWN BRETT HOVLAND (510) 675-6149 <br /> a a ADDRESS <br /> cc P. O. BOX 4023 CONCORD CA 94524 <br /> STREET CITY STATE zip <br /> - <br /> OPERATOR NAME(IF APPLICABLE) OPERATOR PHONE <br /> Z SHELL SERVICE STATION S .Narasimhan / G. Harp 20)9 823-5265 <br /> 0 <br /> a ADDRESS <br /> 0 1071 MAIN North MANTECA SAN JOAQUIN 95336 <br /> 0 <br /> J <br /> w STREET cm <br /> COUNTY <br /> ZIP <br /> CROSS STREET <br /> LOUISE AVENUE <br /> O LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> z SAN JOAQUIN PUBLIC HEALTH DEPT RON ROWE (209) 468-3420 <br /> Lu w w REGIONAL BOARD <br /> a aPHONE <br /> CENTRAL VALLEY REGION ELIZABETH THAYER (916) 255-3133 <br /> LU o (�) NAME QUANTITY LOST(GALLONS) <br /> QGASOLINE UNKNOWN <br /> N0 <br /> [D> (2) <br /> y <br /> 0 UNKNOWN <br /> Z DATE DISCOVERED HOW DISCOVERED 0 INVENTORY CONTROL O SUBSURFACE MONITORING O NUISANCE CONDITIONS <br /> Lu <br /> 2 OMI 8 .11 p 5 0 9 Y 6 Y TANK TEST E] TANK REMOVAL OTHER <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> m <br /> a <br /> w <br /> M D v v UNKNOWN O REMOVE CONTENTS �' CLOSE TANK&REMOVE O REPAIR PIPING <br /> > HAS DISCHARGE BEEN STOPPED 7 �REPAIR TANK a CLOSE TANK&FILL IN PLACE [:]CHANGE PROCEDURE <br /> Uo © YES O NO IF YES,DATE 0 M 8.1 <br /> 10 4 9Y 6 Q REPLACE TANK Q OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> CC:,O TANK LEAK F7 UNKNOWN a OVERFILL a RUPTUREIFAILURE a SPILL <br /> 8 O O PIPING LEAK 0 OTHER Q CORROSION UNKNOWN OTHER <br /> w ww CHECK ONE ONLY <br /> O U UNDETERMINED SOIL ONLY GROUNDWATER a DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> wf--j NO ACTION TAKEN O PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br /> jO LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> U 0 REMEDIATX)N PLAN a CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) 0 CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) F-] EXCAVATE&DISPOSE(ED) 0 REMOVE FREE PRODUCT(FP) O ENHANCED BIO DEGRADATION(IT) <br /> Z (ms7Ts ac FOR D ) <br /> 00 <br /> O CAP SITE(CD) 0 EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT)0 REPLACE SUPPLY(RS) <br /> w a CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) O TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> O VACUUM EXTRACT(VE) OTHER(OT) Site Investigation Planned <br /> U) <br /> r <br /> z <br /> w <br /> o� <br /> U <br /> HSC 05(aW <br />