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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />FOR LOCAL ONLY <br />REPORT BEEN FILED ? <br />YES NO .YES NO <br />❑ ❑ <br />1 HEREBY CERTIFYTHATI. HAVE DISTRIBUTEDTHIS INFORMATION ACCORDING TO7HE:' <br />::DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OFTHIS FORM <br />REPORT DATE <br />CASES <br />9 2J <br />23137 <br />SIGNEa DATE <br />NAME OF INDIVIDUAL FILING REPORT <br />PHONE <br />SIGNATURE <br />> <br />m <br />BernetLa fitas <br />�415)571-2434 <br />wREPRESENTING <br />P!% OWNER/OPERATOR ❑ REGIONAL BOARD <br />COMPANY OR AGENCY NAME <br />0 <br />❑ LOCAL AGENCY ❑ OTHER <br />I <br />ARCM Products Co. <br />Q <br />ADDRESS <br />Q <br />P.O. Box 5811 SagjPateo, CA 94402 ' <br />CRY STATE ZIP <br />w <br />NAME <br />CONTACT PERSON <br />PUHONE <br />z <br />ARCO Products Co. ❑ UNKNOWN <br />Kyle Christie <br />(11.5 )571--2434 <br />a a <br />ADDRESS <br />P.O. Box 5811 (Attns Kyle Christie) Slit Mateo, CA 944012 <br />STREET CITY STATE -.IP <br />FACILITY NAME (IF APPLICABLE) <br />OPERATOR <br />PHONE <br />z <br />O <br />SS# 548 <br />Mohaomad R. Taeb <br />( 2091 478-2723 <br />< <br />0 <br />ADDRESS <br />1612 Ramer Latta , Stockton (.moult Joaquin) � ,�tC' l <br />w <br />STREET CITY COUNTY ZIP <br />N <br />CROSS STREET <br />A Brentwood <br />O <br />LOCAL AGENCY AGENCY NAME <br />CONTACT PERSON <br />PHONE <br />z W <br />Coun::y of San Joaquin <br />Dcmma Hanan <br />(209)468-342(; <br />w U <br />w ww9 <br />REGIONAL BOARD <br />PHONE <br />Central Valley Region (Fresno) <br />John Noonan <br />tom)'45-5 <br />m <br />(1) NAME OUANTITY LOST (GALLONS) <br />WO <br />Petrol.em Bydrocarbom UNKNOWN <br />Q J <br />m z <br />(2) <br />w <br />❑ UNKNOWN <br />Z <br />DATE DISCOVERED <br />HOW DISCOVERED ❑ INVENTORY CONTROL F-1SUBSURFACEMONITORING ❑ NUISANCE CONDITIONS <br />w <br />0 4 2 I aDI 9 YI v <br />❑ TANK TEST � TANK REMOVAL ❑ OTHER <br />a <br />m <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />rc <br />E]UNKNOWN <br />❑ REMOVE CONTENTS;CLOSE TANK & REMOVE ❑REPAIR PIPING <br />Uj <br />p <br />M M D D Y Y <br />❑ REPAIR TANK F7CLOSE TANK & FILL IN PLACE E:]CHANGE PROCEDURE <br />HAS DISCHARGE BEEN STOPPED 7 <br />oYES <br />❑ NO IF YES, DATE 4 4 2 8 9 2 <br />REPLACE TANK E::]OTHER <br />M MI D D v v❑ <br />w <br />SOURCE OF DISCHARGE <br />CAUSE(S) <br />¢ U <br />❑ TANK LEAK UNKNOWN <br />❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br />U) U <br />❑ PIPING LEAK ❑ OTHER <br />❑ CORROSION UNKNOWN ❑ OTHER <br />Lu w <br />CHECK ONE ONLY <br />U <br />❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY <br />w <br />❑ NO ACTION TAKEN F7 PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br />y <br />0 LEAK BEING CONFIRMED 0 PRELIMINARY SITE ASSESSMENT UNDERWAY E_POST CLEANUP MONITORING IN PROGRESS <br />U <br />❑ REMEDIATION PLAN 0 CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br />CHECK APPROPRIATE ACTION(S) EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) <br />0 0 <br />I-� <br />ISEE S-ZK Fos MALS) I�- <br />❑ CAP SITE (CD) ❑ EXCAVATE & TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />w F - <br />Q¢ ❑ <br />CONTAINMENT BARRIER (CB) E:] NO ACTION REQUIRED (NA) ❑ TREATMENT AT HOOKUP (HU) ❑ VENT SOIL (VS) <br />❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br />;..o i 1 sample obtained th of li watex separator <br />w <br />TP11 by 418.1-400 pplm. Qi t4w sep"toi- 1-amoved fmom Afacillty. <br />0 <br />U <br />