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k ` t <br /> UNDERGROUND STORAGE TANK'UNAUTHORIZED RELEASE (LEAK-)/CONTAMINATION SITE REPORT <br /> EMERGENCY 'HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOQALAGENGY UStONLY <br /> ❑ YES NO REPORT BEEN FILED? ,F YES NO I HEREBY CEFITIFY NAT I AM:A DESIGNATED GOYFANMENT EMPLOYES ANQ THAT t HAVE <br /> REPORT b.TRIS INFORMATION TD =AL.OFFICIALS POR'SU, NT Ta.SEGT10M 25�Bd7 OF' <br /> REPORT DATE CASE A TFI HFA)TSE ANF $liFTY LSE`: <br /> 5 { <br /> M1 S -1 531 .3 DI -RI 'R J - : .:.: ::: -� , : : ISIGNED r:: <br /> tMTf':: <br /> NAME OF INDIVIDUAL FILING REPORT PHONE I S ATUAE <br /> Diane H. Hinson )468-3441 <br /> REPRESENTING ❑ OWNEFVOPERATQq ❑ .REGIONAL BOARD COMPANY OR AGENCY NAME <br /> p � LOCAL AGENCY ❑ OTHER <br /> San Joaquin Local Health Distric.i: <br /> ADDRESS <br /> ASTREET E. Hazel ton---Avenue CITY"St 6k to v STA <br /> NAMEME ^CONTACTPERSON :} PHONE <br /> City of Stockton Public Works EJUNKNOWN :;Harry Montagomery 12090 944-8282 F <br /> a ADDRESS <br /> LU Ci ty Hal 1 �� S <br /> STREET STATE CA q6202 <br /> FACILITY NAME(IF APPLICABLE) OPEAATQR PHONE <br /> Z Fire Engine ne Company #2 } <br /> 0 9 p Y Cit of Stockton Fire Dept- (209 i) 944-8271 <br /> a ADDRESS <br /> 110 STREE' West Sonora Street ; Crry 'tockton San n' uin 205 <br /> Fn CROSS STRE ET TYPE OF AREA c�.,lM f F <br /> COMMERCIAL INDUSTRIAL ❑RURAL TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> Washington ❑RESIDENTIAL E—]OTHER 0 FARM ® OTHERf i r^p S f tj p� <br /> 9 LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE- <br /> t <br /> co <br /> W LU <br /> San Joaquin )46 <br /> _ <br /> w REGIONAL BOARD 9441 <br /> PHONE 09 <br /> a Central Valley -- 0 A. Vorster' I <br /> X16 �) 3615600 <br /> (�) NAME QUANTITYLOST(GALLONS) <br /> I <br /> Petroleum Hydrocarbons UNKNOWN <br /> �o <br /> czJ " Ii <br /> ' ❑ UNKNOWN <br /> w DATEDISCOVEREO HOWOISCOVERED ❑ INVENTORY CONTROL SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> 0 .13 .1 0 0 9 . D1 N8 Y TANKTEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN I METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) I` <br /> Ii UNKNOWN _ ❑ ',REMOVE CONTENTS ❑ REPLACE TANK ®CLOSE TANK <br /> W <br /> M M Y Y f <br /> p HAS DISCHARGE BEEN STOPPED? gEAAIR TANK!. <br /> C� :Q I_ ❑ REPAIR PIPING ❑ iCHANGE PROCEDURE <br /> o YES F�] NO IFYES,DATEQ ( 0 0 .o S Y ] Y ❑_OTHER <br /> W SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL <br /> CAUSE(S) <br /> .¢s <br /> ❑ TANK LEAK XX UNKNOWN 1,000 GAL. ❑ FIBERGLASS ❑ OVERFILL 0 RUPTUREIFAILURE x <br /> ❑ PIPING LEAK AGE YRS `STEEL. k ❑ CORROSION UNKNOWN <br /> �j ❑ OTHER �❑ UNKNOWN ❑ OTHER _ <br /> ID SPILL E::] OTHER <br /> WW CHECK ONE ONLY <br /> CL II <br /> ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATERT°- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY ti <br /> Z(a - 1p <br /> ELY C XU SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN,PROGRESS SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> U`4 ❑ 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 /> 5 z ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE[ED} ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> LU <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT.[ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> WFurther site assessment will be required ' to determine the nature and extent of <br /> contamination, as required by ..the appropriateregulatory agency. <br /> i�. <br /> . HSC O544AM <br /> F <br />