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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICESFM t�AL'AGENCY USE ONLY.:.: <br /> ❑ YES ® NO REPORT BEEN FILED 7 <br /> ❑ YES NO 1 HEREBY CERTIFYTHAT)HAVE DISTRIBUTEDTHIS INFQAMATICA ;per <br /> REPORT DATE CASES DSMIBUTION SHOWN ON THE.INSTRUCTION SHEET.ON THE SACK PAGE OFTHIS , <br /> X. <br /> 0 MI 8 mi 0 2 9 4 y sIGKEo <br /> DATE> <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SKaIdATURE <br /> ® C. Susi Jackson (510 ) 423-6577 <br /> LU REPRESENTING ® OWNERIOPERATOR �❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> Cc <br /> Uj ❑ LOCAL AGENCY [-1 OTHER University of California <br /> cADDRESS <br /> P.O. Box 808 L-633 � 7000 East Ave. rm, Livermore �„� CA. 455 <br /> W NAME <br /> CONTACT PERSON - <br /> PHONE <br /> Z iz Dennis K. Fisher ❑ UNKNOWN I C. Susi Jackson <br /> =6DRESs (510 ) 423-6577 <br /> M <br /> W <br /> cc P.O. Box 808, L-633 mLr 7000 East Ave. c,n, Livermore STATE <br /> 9050 <br /> FACILITY AERATOR <br /> NAME(IF APPLICABLE) <br /> Lawrence Livermore National Laboratory PHONE <br /> o Site 300 Building 871 1 Dennis K. Fisher (510 ) 422-3343 <br /> c ADDRESS <br /> W Corral Hollow Road �, <br /> South o CITY y San Joaquin <br /> y CROSS STREET <br /> Interstate 580 <br /> OLOCAL AGENCY <br /> 2 0.,, ar <br /> .....Y°4AA.� CONTACT PEKE ,'.'N p►{ONC '1I <br /> = I f <br /> W y <br /> Sano� County-J3___ ,uin ,..Pubjic Health Scr, cls William Snavely {70;� a 468-0336 9 <br /> vi � <br /> I ,w Ai:G iNAL BOARD �. <br /> Central Valle RW CB 55- <br /> `' y Q Susan T�,am � t y 16 ) 255-3057 _ <br /> w (�) NAME QUANTITY LOST <br /> 0 <br /> Diesel Fuel <br /> UNKNOWN <br /> y> <br /> m <br /> M? <br /> h <br /> UNKNOWN <br /> = DATE DISCOVER:�6::o9 <br /> T, 7F�7TANK <br /> W ® INVENTORY CONTROL ❑ SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> w 0 MI 7 .12 y T ® TANK REMOVAL ® OTHER Smell Of DiPscel fuel iII Soil <br /> am GATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> W ® UNKNOWN ❑REMOVE CONTENTS ®CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> Q <br /> > Y <br /> O HAS DISCHARGE BEEN STOPPED 7 REPAIR TANK CLOSE TANK&FILL IN PLACE CHANGE PROCEDURE <br /> U) Tank Pumped ® ❑ <br /> p Eil YES ❑ NO IF YES.DATE 0 M 7 j 2 p 1 9 yj 4 y, 1:1 REPLACE TANK ®OTHER <br /> 0 SOURCE OF DISCHARGE0 LU CAUSE(S) <br /> aTANK LEAK <br /> F7 TANK UNKNOWN ® OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> U ❑ PIPING LEAK ® OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> U ww CHECK ONE ONLY <br /> CL <br /> U ❑ UNDETERMINED ® SOIL ONLY ❑ <br /> CHECK ONE ONLY GROUNDWATER [:] DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> zQ NO ACTION TAKEN F7 PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> vy ❑ LEAK BEING CONFIRMED ® PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATED�ACTIpN(g) <br /> � ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) [:] ENHANCED BIO DEGRADATION(IT) <br /> p p ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> Q a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) F7 VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ® OTHER(OT) Remove tank & overexcavate <br /> Wy Sensory evidence suggested dispersed contamination in the bottom of the excavation. <br /> aSuspected impacted soil was excavated and sampled. Tank testing had shown this tank <br /> to be leak tight. <br /> U <br />