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th , vy <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FPR LOCAL AGENCY IUSE ONLY <br /> ❑ YES ® NO <br /> REPORT BEEN FILED? ❑ YES ❑ NO ( RESYCERTIFYIH11TI H&E DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DIS GUT GN SHV E INSTRUCTION SHEET ON THE BACK PAG9rOFT14S FORM <br /> REPORT DATE CASES <br /> A4- <br /> Oml 8 MI 0 3 9 4 Y slGraEn DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGN RE <br /> C. Susi Jackson (510 ) 423-6577 <br /> W REPRESENTING © OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> p ❑ LOCAIAGENCY ❑ OTHER University of California <br /> W ADDRESS <br /> P.O. Box 808, L-633 STREET 7000 East Ave. CITY Livermore STATE CA 9455 0 <br /> w NAME CONTACTPERSON PHONE <br /> J <br /> z Dennis K. Fisher E:] UNKNOWN C. Susi Jackson (510 ) 423-6577 <br /> O a ADDRESS <br /> P.O. Box 808 L-633 7000 East Ave. Livermore CA 94550 <br /> f STREET CITY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> Lawrence Livermore National laboratory <br /> o Site 300 Buildin 834 Dennis K. Fisher (510 ) 422-3343 <br /> < ADDRESS <br /> Corral Hollow Road STREET CITY South of Tracy �o a/n Joaquin <br /> Z(P <br /> CROSS STREET <br /> Interstate 580 <br /> O LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> Z o San Joaquin Count Public Health Service William Snavely (209 ) 468-0336 <br /> LU n REGIONALBOARD PHONE <br /> Central Valley RWQCB Susan Timm (916 ) 255-3057 <br /> rn (1) NAME QUANTITY LOST(GALLONS) <br /> QWO ® UNKNOWN <br /> > Diesel Fuel <br /> CD o (Z) <br /> Z)z <br /> UNKNOWN <br /> ZDATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING E] NUISANCE CONDITIONS <br /> Lij w 0 MI 7 MI 2 D 7 DI 9 v� 4 Y ❑ TANK TEST ® TANK REMOVAL © OTHER Smell of diesel fuel in soil <br /> F- <br /> < DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> CD <br /> g <br /> M M D D Y Y <br /> W <br /> ❑ UNKNOWN ❑REMOVE CONTENTS O CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> p HAS DISCHARGE BEEN STOPPED? Tank Pumped ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> U) <br /> © YES ❑ NO IF YES,DATE OM 7 MI 2 D 1 D 9 Y 4 Y ❑REPLACE TANK ❑ OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> QLLJ <br /> j ❑ TANK LEAK ❑ UNKNOWN FX OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> U U ❑ PIPING LEAK ® OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> U,wCHECK ONE ONLY <br /> U F-1 UNDETERMINED E:] SOIL ONLY ® GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w Cn PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED E::] POLLUTION CHARACTERIZATION <br /> ❑ NO ACTION TAKEN ❑ <br /> Cr <br /> ❑ LEAK BEING CONFIRMED © PRELIMINARY SITE ASSESSMENT UNDERWAY E:j POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) C <br /> J (SEE BACK FOR DETACS) <br /> a z ❑ <br /> 0 O CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> Uj <br /> LU a F-] CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ® OTHER(OT) Remove tank & overexcavate. <br /> ExcavATION SMELLED OF DIESEL FUEL. SUSPENDED IMPACTED SOIL WAS EXCAVATED AND SAMPLED. <br /> w DIESEL FUEL ALSO IDENTIFIED IN GROUNDWATER FROM NEARBY DOWNGRADIENT WELL MONITORING <br /> o AN 18 FOOT DEEP PERCHED AQUIFER. TANK TESTING HAD SHOWN THIS TANK TO BE LEAK TIGHT. <br /> U <br /> HSC 05190) <br />