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�.- <br /> UNAUTHORIZEDUNDERGROUND STORAGE TANK (LEAK)/CONTAMINATION SITEPRT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES E RLOCALAGENCTUSE ONLY <br /> ❑ YES ® NO REPORT BEEN FILED? ❑ YES ❑ No J H REV CERTIF AT t.H VE DISTRIBUTED THIS INfORMA71ON ACCOR.ING T THE <br /> DIS 1 U RON S E INSTRUCTION SHEET ON THE BACK PAGE f THI ORM <br /> REPORT DATE CASE A <br /> 0 ml 8 .10 d 2 d 9 4 Y s�wEo ATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIG R <br /> C. Susi Jackson (510 ) 423-6577 <br /> W REPRESENTING REGIONAL BOARD COMPANY OR AGENCY NAME <br /> OWNERIOPERATOR <br /> 2 ❑ LOCAL AGENCY ❑ OTHER University of California <br /> W ADDRESS <br /> P.O. Box 808 L-633,,,E, 7000 East Ave. Cm Livermore STATE CA. J455 <br /> W NAME CONTACT PERSON PHONE <br /> J <br /> z Dennis K. Fisher E] UNKNOWN C. Susi Jackson (510 ) 423-6577 <br /> O`� ADDRESS <br /> Ua <br /> P.O. Box 808, L-633 STREET 7000 East Ave. <br /> Cm Livermore STATE CA 94550 <br /> PHONE <br /> FACILITY NAME(IF APPLICABLE) OPERATOR <br /> Lawrence Livermore National Laboratory <br /> o Site 300 Building 871 Dennis K. Fisher (510 ) 422-3343 <br /> a ADDRESS <br /> 2 Corral Hollow Road STREET South of Tracy SaCITY t OU Joaquin ZIP <br /> W <br /> CROSS STREET <br /> Interstate 580 <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> W o San Joaquin County Public Health Services William Snavely (209 ) 468-0336 <br /> w REGIONAL BOARD PHONE <br /> a Central Valley RWQCB Susan Timm (916 ) 255-3057 <br /> y (t) NAME QUANTITY LOST(GALLONS) <br /> W <br /> OW Diesel Fuel UNKNOWN <br /> ®o (2) <br /> Nz <br /> ❑ UNKNOWN <br /> Z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING [:] NUISANCE CONDITIONS <br /> 0 MI 7 .12 06 0I 9 y4 y ❑ TANK TEST ® TANK REMOVAL ® OTHER Smell of Diesel fuel in soil <br /> 'z DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> m <br /> `r <br /> ® UNKNOWN ❑REMOVE CONTENTS ®CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> LU M M ® v Y <br /> p HAS DISCHARGE BEEN STOPPED? Tank Pum ed ❑REPAIR TANK CLOSE TANK&FILL IN PLACE E:]CHANGE PROCEDURE <br /> Eil <br /> YES ❑ NO IF YES,DATE 0 M 7 M1 2 ® 1p®19 ,14 Y ❑REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> CC 5 ❑ TANK LEAK ❑ UNKNOWN ® OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> U ❑ PIPING LEAK ❑x OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> W�a CHECK ONE ONLY <br /> U� E] UNDETERMINED a SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w F--] NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> tr I ❑ LEAK BEING CONFIRMED © PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> J tSEE eAcrc FOR oESAes1 <br /> ®O <br /> ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> rt ❑ VACUUM EXTRACT(VE) ® OTHER(OT) Remove tank & overexcavate <br /> Sensory evidence suggested dispersed contamination in the bottom of the excavation. <br /> W Suspected impacted soil was excavated and sampled. Tank testing had shown this tank <br /> o to be leak tight. <br /> U <br /> HSC 05(fl^Stn <br />