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I . 0 0 c7 S—L)03 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br /> FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED? <br /> O YES � NO � YES O NO 1 HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEETGkJHE BWK PAGE OF THIS FORM <br /> REPORT DATE I CASE$ <br /> i M, 2 MI O d 7 d 9 ,� 4,1 SIGNED pp . <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGN RE <br /> m <br /> KAREN D. CLARK (510) 675-611 4 <br /> REPRESENTING Ej OWNER/OPERATOR REGIONAL BOARD COMPANY OR AGENCY NA <br /> 2 [:] LOCAL AGENCY [—] OTHER SHELL OIL COiIiPANY <br /> cc ADDRESS <br /> 1390 WILLOW PASS RD. , SUITE 900 CONCORD CA 94524 <br /> STREET CRY STATE ZIP <br /> w NAME CONTACTPERSON PHONE <br /> Z SHELL OIL COMPANY UNKNOWN DAN KIRK (510 )675-6168 <br /> o� <br /> a a ADDRESS <br /> ca <br /> cc 1390 WILLOW PASS RD, STE 900 CONCORD CA 94524 <br /> STREET CITY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> z COUNTRY CLUB SHELL CRAIG FURGISON � ( 20� 948-0574 <br /> 0 <br /> < ADDRESS <br /> U <br /> ° 2575 COUNTRY CLU REET STOCKTTON SA ��,�OA UIN Z�P952 4 <br /> w <br /> ~y CROSS STREET <br /> PLYMOUTH <br /> �ry LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> W� SAN jOAQUIN CO, ENV HEALTH DOUG WILSON MIKE Ki ( 209) 468-3444 <br /> w w REGIONAL BOARD PHONE <br /> CENTRAL VT REGION W.R. C.B. E. THAYER � (916) 361-5600 <br /> w (t) NAME QUANTITY LOST(GALLONS) <br /> Q>w RU GASOLINE QUANTITY REPORTED PER OPERATOR RECORDS 8, 500 UNKNOWN <br /> r <br /> m O] (2) <br /> z <br /> cn C UNKNOWN <br /> z DATE DISCOVERED HOWDISCOVERED INVENTORY CONTROL SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> w 1 MI SAI O DI 7 DI 9 rI 4 Y RR TANK TEST TANK REMOVAL OTHER <br /> < DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> 1 2 07 9 4 O UNKNOWN [ eEMOVE CONTENTS CLOSE TANK&REMOVE EDREPAIR PIPING <br /> w M M D D Y Y <br /> HAS DISCHARGE BEEN STOPPED? REPAIR TANK CLOSE TANK&FILL IN PLACE E]CHANGE PROCEDURE <br /> o Eg YES E:] NO IF YES,DATE lO OTHER <br /> MI 2MI 0 D 7 DI 9 rl 4REPLACE TANK <br /> LZ SOURCE OF DISCHARGE CAUSE(S) <br /> Lu <br /> a TANK LEAK UNKNOWN OVERFILL RUPTURE/FAILURE O SPILL <br /> w U PIPING LEAK OTHER CORROSION a UNKNOWN O OTHER <br /> w w CHECK ONE ONLY <br /> rn IL <br /> U UNDETERMINED SOIL ONLY GROUNDWATER = DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z 0 NO ACTION TAKEN PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED 0 POLLUTION CHARACTERIZATION <br /> Lu <br /> ¢_N O LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> U <br /> REMEDIATION PLAN � CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) � CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) <br /> Iscf 8..G1(FOR DETAIS) EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) O ENHANCED BIO DEGRADATION(IT) <br /> � <br /> Z <br /> O O CAP SITE(CD) Q EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT)O REPLACE SUPPLY(RS) <br /> w< CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> VACUUM EXTRACT(VE) OTHER(OT) UNDIER INVE S T I GAT I ON <br /> ti <br /> z <br /> EAJO <br /> U <br /> HSC 05(8^90) <br />