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4 i$ <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OFEMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY _ ° <br /> REPORT BEEN FILED? I HEREBY CERTIFY THAT i AM A:DESIGNAT GOVERNMENT,EMPLOYEE AN4 THATa HAVE. <br /> ❑ YES NO FJ YES ❑ NO AEPORTFa.Ft1}S)NEORMAT10�1 TO L()CAL i'-wkPtlRS FTQ SE T(.. 2 Fab0'1 OF <br /> THE NE1Y ?.:.. >:[?:E :•:..::.;;:>::: <br /> REPORT DATE CASE#� A <br /> ?::"• iti:fi '' <br /> :v...............k....y ....... :::::.-. <br /> :. ::.>;}:vi:;:::::::........:{• .....:..P.:::::ii..y,.;:'•:'•i:t•:S;i:::;iJw: ::-vivv.•.:::....;..., <br /> :i:H¢;v 4. <br /> tm <br /> M M D 'D Y Y ... ., <br /> NAME OF INDIVIDUAL FILING REPORT PHONE 1-800-451— SIGNATUFf- <br /> DANIEL T. KIRK ( )194-134 E er, 1 <br /> REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME �. <br /> ❑ LOCALAGENCY ❑ OTHER S1ELiL; IL COMPANY <br /> Q ADDRESS <br /> 1390 WILLO PASS ROAD STE. 900 CONCORD CA. <br /> STFI[EEr CITY SrnTE ZIP <br /> NAME CONTACT PERSON PHONE <br /> ca SHELL OIL COMPANY127 <br /> Fn Q❑ UNKNOWN DIANE LUNDQUIST ( ) — <br /> k i <br /> R a ADDRESS <br /> s SAME AS ABOVE OR P.9*JOX 4023 COJgORD <br /> ST <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> SHELL STATION ,BERT.LUTZl (2094 <br /> o 2 <br /> 943-1311.: <br /> ADDRESS <br /> 2320` RI. EL DORADO S ' EEf ^XQCKTQN SgcJQAQUIN ZIP <br /> wCROSSSTREET TYPE OF AREA ❑COMMERCIAL ❑INDUSTRIAL❑RURAL TYPE OF BUSINESS ®.'RETAIL FUEL STATION <br /> ADAMSST. E]RESIDENTIAL F—]OTHER ❑ FARM E::] OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE " <br /> wW SAN JOAQUIN. CO. ENVIROMENTAL HEALTH KASEY F019Y ( 204 468-3424` ° <br /> w w REGIONAL BOARD PHONE <br /> n. <br /> a LMRkAL VALLEY ( ) <br /> (q) NAME QUANTITY LOST(GALLONS) <br /> Q W SUSPECT WEATHERED GASOLINE ® UNKNOWN ice} <br /> z (2) <br /> U)' — UNKNOWN <br /> s Z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> ul <br /> ml 4ml 6 D -1 9 Y1 Y ❑ TANK TEST ❑ TANK REMOVAL ❑ OTHER <br /> `DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY a <br /> Q ❑ ❑ REMOVE CONTENTS ❑ REPLACE TANK CLOSE TANK <br /> UNKNOWN <br /> W M M D D Y y .�-- <br /> 0 HAS DISCHARGE BEEN STOPPED 7 ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> I <br /> R <br /> p ❑ YES ❑ NO IF YES,DATE M M D D y y ❑ OTHER N ' <br /> 5 <br /> x <br /> N SOURCE OF DISCHARGE TANKS ONLYICAPACITY MATERIAL CAUSE(S) a <br /> ❑ TANK LEAK ❑ UNKNOWN --R m 1-10M GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE <br /> r 2 ❑ PIPING LEAK AGE ZZ YRS ❑ STEEL ❑ CORROSION EV UNKNOWN rY <br /> ku ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> ,;'I <br /> C ,r.• <br /> Lu <br /> CHECK ONE ONLY , <br /> - ❑ UNDETERMINED Q SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) tj <br /> t.. <br /> CHECK ONE ONLY <br /> ¢ ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) E::] CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) fid. <br /> V N ❑cr <br /> POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> E:] NO ACTION TAKEN ) 3 <br /> t" <br /> CHECK APPROPRIATE ACTIONS SEE BACK FOR DETAILS <br /> Z5 zO ❑, CAP SITE(CD). ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) 5 <br /> f <br /> w - <br /> 2 <br /> D CONTAINMENT BARRIER(CB) ❑ EXCAVATE 8 TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) '} <br /> ❑cc <br /> TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) Et OTHER(OT) TO BE_DETERMINED / <br /> PERMITTING IN PROGRESS TO REPLACE TAW. NEW 'TANKS WILL BE PLACED INALTERNATE <br />( . w LOCATION. !; <br /> I ' <br /> w ,.." HSC 0.5(4/87) y°` <br />