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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />;AOR LOCAL, AGENCTUSE. ONLY <br />REPORT BEEN FILED ? <br />❑ YES NO YES ❑ NO <br />I HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br />DISTR IBUT100HOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM. <br />REPORT DATE <br />CASE 3 <br />Q1 51 q 4 9 2 r <br />2 313 7 <br />swEa DATE <br />NAME OF INDIVIDUAL FILING REPORT <br />PHONE <br />SIGNATURE <br />® <br />Bernetta Wess <br />(415) 571-2434 <br />w <br />REPRESENTING OWNER/OPERATOR ❑ REGIONAL BOARD <br />COMPANY OR AGENCY NAME <br />R <br />❑ LOCAL AGENCY ❑ OTHER <br />I <br />CO Products Co. <br />¢ <br />ADDRESS <br />P.O. Box 5811 SapRE ateo, CA 94402 CPTr STATE ZIP <br />W <br />NAME <br />CONTACT PERSON <br />PHONE <br />J <br />Fn <br />CO Products Co.0 UNKNOWN I <br />Ryle Christie 1(415)571-2434 <br />O <br />a < <br />ADDRESS <br />¢a <br />P.O. Box 5811 (Attn: Ryle Christie) San Mateo, CA 94402 <br />STREET CITY STATE Ip <br />FACILITY NAME (IF APPLICABLE) <br />OPERATOR <br />PHONE <br />o <br />SS# 548 <br />Mohammad A. Taeb <br />(209) 478-2723 <br />ADDRESS <br />1612 Hammer Lane ® Stockton (San Joaquin) <br />W <br />STREET CITY COUNTY ZIP <br />CROSS STREET <br />Brentwood <br />cB <br />LOCALAGENCY AGENCY NAME <br />CONTACT PERSON <br />PHONE <br />� W <br />County of San Joaquin <br />Donna Heran <br />(209)468-3420 <br />W U <br />w w <br />J C3 <br />REGIONAL BOARD <br />PHONE <br />CL <br />Central Valley Re ion (Fresno) <br />John Noonan <br />(209)445-5116 <br />(1) NAME QUANTITY LOST (GALLONS) <br />® <br />OW <br />Petroleum Hydrocarbons UNKNOWN <br /><, J <br />m z <br />(Z) <br />N <br />❑ UNKNOWN <br />z <br />DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL F-1SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br />LU <br />M®I <br />4 oI 8 I 9 E:] TANK TEST TANK REMOVAL ❑ OTHER <br />Y72:v <br />r <br />® <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />cc <br />a UNKNOWN <br />M DI r v <br />❑ REMOVE CONTENTS CLOSE TANK & REMOVE REPAIR PIPING <br />W <br />® <br />❑REPAIR TANK ❑ CLOSE TANK & FILL IN PLACE ❑ CHANGE PROCEDURE <br />HAS DISCHARGE BEEN STOPPED? <br />U <br />CD <br />JRYES ❑ NO IF YES, DATE Om, 4 2®8 9 2 <br />❑ REPLACE TANK Q OTHER <br />0 <br />MI v v <br />� LU <br />SOURCE OF DISCHARGE <br />CA USES) <br />Ca <br />❑ TANK LEAK UNKNOWN <br />a OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br />0 O <br />❑ PIPING LEAK ❑ OTHER <br />❑ CORROSION UNKNOWN ❑ OTHER <br />www <br />CHECK ONE ONLY <br />U 9 <br />❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY <br />QiR <br />❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br />D ;� <br />Cn <br />F-1LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY F__]POST CLEANUP MONITORING IN PROGRESS <br />U <br />❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br />J <br />CHECK APPROPRIATE ACTION(S) EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) <br />(SEE SA" FOR MARS) <br />wp <br />F-1CAPSITE (CD) ❑ EXCAVATE & TREAT (ET) F -]PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />LU a <br />F-]CONTAINMENTBARRIER (CB) E] NO ACTION REQUIRED (NA) ❑ TREATMENT AT HOOKUP (HU) ❑ VENT SOIL (VS) <br />❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br />Soil sample obtained immediately beneath oil/water seperator, <br />TPH by 418.1=400 ppm. Oil/dater Sepertor removed from facility. <br />0 <br />O <br />U <br />HSC 05 (&W <br />