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01 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE <br /> - 11 <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICESQ(t L LAGENGY USE QI$Y <br /> REPORT BEEN FILED? (:1aPE�E$Y.RPfPT1FY 7FfAT i AM A RPS TPR GQ fi NT:'MPLOY.EP M-P CHAT E HAVE: <br /> ❑ YES ® No ❑YES a R f3 FlltS TNF T1QN TQ L( ,P. [C:AIS PURSUAN Tt7 SECT 251807 OF <br /> REPORT DATE CASE N TPdP H <br /> Oml 5 1 2 p 0 p 9 y 2 y zSIGKEd .: .. <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> C. Susi Jackson (510 ) 423-6577 ,S. <br /> a REPRESENTING ® OWNEWOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> ® ❑ LOCALAGENCY ❑ OTHER University of California <br /> W <br /> cc ADDRESS <br /> P.O. Box 808, L-633, 7000 East Avenue Livermore CA 94550 <br /> STREET CITY STATE ZIP <br /> NAME CONTACTPERSON PHONE <br /> ti� Dennis K. Fisher ❑ UNKNOWN C. Susi Jackson (510 ) 423-6577 <br /> a ADDRESS <br /> P.O. Box 808, L-668, S 8000 East Avenue E 9/- 50 <br /> FACILITY NAME(IF APPLICABLE) Building 875 OPERATOR PHONE <br /> Lawrence Livermore National Lab. - Site 400 Dennis K. Fisher 010 ) 422-3343 <br /> a ADDRESS <br /> Corral Hollow Rd, So. of Tracy San Joaquin County <br /> STREET CRy COUNTY P <br /> yCROSS STREET TYPE OF AREA ❑COMMERCIAL❑ INDUSTRIAL❑RURAL TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> Interstate 580 ❑RESIDENTIAL MOTHER Federal Lab ❑ FARM %© OTHER Research <br /> OCAL 9GENCY AGENCY NAME CONTACT PERSON PHONE <br /> 'J <br /> , an Joaquin County <br /> zW Public Health Service William Snavely ( 209) 468-0336 <br /> W <br /> w W REGIONAL BOARD PHONE <br /> M Central Valley RWQCB Wendy Cohen ( 916) 361-5676 <br /> (1) NAME QUANTITY LOST(GALLONS) <br /> HDiesel Fuel ® UNKNOWN <br /> �i- ❑ UNKNOWN ONO <br /> z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS a <br /> 2 0 5 M 1 p 3 p 9y 2 y ❑ TANK TEST RR TANK REMOVAL ❑ OTHER } <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M .1 D .1 Y1 Yi 0 UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK ® CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED? Unknown ❑ REPAIR TANK ❑ REPAIR PIING ❑ CHANGE PROOEDURE <br /> ® ® YES ❑ NO IF YES,DATE I M p .1 y YL ❑ OTHER <br /> u� SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> ❑ TANKLEAK ❑ UNKNOWN 3000 GAL. ❑ FIBERGLASS FX:� OVERFILL ❑ RUPTURE/FAILURE <br /> AGE 35 YRS X STEEL CORROSION <br /> ❑ PIPING LEAK UNKNOWN <br /> ac <br /> ❑ OTHER overf ill ❑ UNKNOWN ❑ OTHER ❑ SPILL —] OTHER <br /> CHECK ONE ONLY fillg r 1 <br /> O <br /> E:] UNDETERMINED ® IoGROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONF ONLY <br /> Cr. ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> U 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 /> ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> F--] CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP 8 TREAT GROUNDWATER(G R ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ® OTHER(OT) Dispose <br /> y The releases are believed to be related to historic overfill events. <br /> W There is no recent evidence of leakage or spillage. <br /> NSCos(w <br />