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UNDERGROUND STORAGE TANK UNAUTHORIZED ! (LEAK)/CONTAMINATION SITET EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCYUSEONLY REPORT BEEN FILED 7I HEREBY CERTIFYTHAT i HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE: O YES NO YES NO ;DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF-THIS FORM. REPORT DATE CASE x M l 2 l 9 7 y sr,ED DATE NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE r JERRY YOSHIOKA (209 ) 468-0335 O REGIONAL BOARD COMPANY OR AGENCY NAME w REPRESENTING ❑ OWNER/OPERATOR g LOCAL AGENCY E:] OTHER SAN JO.PAQUIN CO Y ROAMENIPAL HEALTIH � ADDRESS 304 E. WEBER AVENUE, THIRD FLOOR, STOCKTON CA 95202 STREET C(Ty - STATE ZIP w NAME CONTACT PERSON PHONE J U) IQBA,L CHOHAN ❑ UNKNOWN IQBAL CHOHAN 1109 ) 364-6437 0 a ADDRESS Cc 444 MOSSDALE STREET T OP STATE CA IP FACILITY NAME(IF APPLICABLE) OPERATOR PHONE o CAI, TEXACO IQ CHO (209) 364-6437 ADDRESS g 444 MOSSD.ALEw STREQ L,ATHROP� SAN JOA�Qq�i ZIP F= CROSS STREET I — 5 Q LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE z W SAN JOAQUIN CO. ENVIRONMENTAL HEALTH JERRY YOSHIOKA (209) 468-0335 w U w w REGIONAL BOARD PHONE CLta co (,I NAME QUANTITY LOST(GALLONS) a> UNLEADED GASOLINE ® UNKNOWN Woca> f2I �z O UNKNOWN Z DATE DISCOVERED HOW DISCOVERED F—] INVENTORY CONTROL ❑ SUBSURFACE MONITORING ® NUISANCE CONDITIONS w MI 1M 1oI 4oI 9y 7y O TANK TEST ® TANK REMOVAL ® OTHER FLOOD INVESTIGATION m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) M ® y y UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING p HAS DISCHARGE BEEN STOPPED 1 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE 2 YES O NO IF YES.DATE 0 1 MO 0 4. 9 y 7 y ❑REPLACE TANK ® OTHER 'PL000 ]� CEUEU, SOURCE OF DISCHARGE CAUSE(S) a O TANK LEAK ❑ UNKNOWN O OVERFILL ❑ RUPTURE/FAILURE O SPILL c O ❑ PIPING LEAK ® OTHER ❑ CORROSION ❑ UNKNOWN OTHER FLOOD Q)a CHECK ONE ONLY o GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) UNDETERMINED O SOIL ONLY ® CHECK ONE ONLY z NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION ui cc ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ny REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) J (SEE SACK sat MALS) —as o® ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GI)❑ REPLACE SUPPLY(RS) r Lu a O CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) VENT SOIL(VS) cr ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) z REMOVAL OF FUEL/WATER FROM UNDERGROUND STORAGE TANKS. UST SYSTEMS TO BE TIGHTNESS TESTED. INVESTIGATION TO DETERMINE THE QUANTITY U RELEASED. HSC 05(a"