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i <br />pI -- M - L11 - U1_ T r <br />NAME OF INDIVIDUAL FILING REPORT <br />CHECK ONE ONLY <br />_ ,.... _...... ............... <br />PHONE <br />SIGN RE AGENT R CO <br />Alice Scheufler <br />,SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />(408)984-6536 <br />CHECK ONE ONLY <br />REPRESENTING ® OWNERIOPERATOR <br />❑ , REGIONAL BOARD <br />COMPANY OR AGENCY NAME <br />❑ LOCAL AGENCY ❑ OTHER <br />j cc N <br />❑ LEAK BEING CONFIRMED <br />PACIFIC ENVIRONMENTAL GROUP, INC. <br />O <br />❑ REMEDIATKOV PLAN <br />❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br />ADDRESS <br />CHECK APPROPRIATE ACTIONS) <br />❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) <br />1601 Civic Center e <br />#202 <br />Santa ,lana C STATE 95050 ZIP <br />NAME <br />❑ CONTAINMENT BARRIER (CB)NO ACTION REQUIRED (NA) ❑ TREATMENT AT HOOKUP (HU) ❑ VENT SOIL (VS) <br />coNTacTPERsoN ° PHONE <br />ARCO PETROLEUM PRODUCTS <br />° - a "( 415) 571 -2482 <br />❑ UNKNOWN Elaine L ivine �//�g <br />ADDRESS <br />P.O. Box 5811 <br />Customer drove off with nozzle still in car. Filter blew out. Dealer took care <br />(� <br />(�� <br />A i" Lk <br />San Mateo CA-, 94402 <br />STREET <br />g <br />C 3'.''� " `,`-. ``. . AT ' i ZIP <br />FACILITY NAME (IF APPLICABLE) <br />OPERATOR P E R Ns I T S��- e € 4 a PHONE <br />=, bl��,• a . � <br />ARCO Station No. 5450 <br />Edward A. Isaacson (209) 462-1617 <br />ADDRESS <br />1617 West Fremont <br />Stockton San Joaquin 95203 <br />3TREEP <br />GTY COUNTY ZIP <br />CROSS STREET <br />I-5 <br />LOCAL AGENCY AGENCY NAME <br />CONTACT PERSON PHONE <br />San Joaquin Local Health <br />Ms. Lori Cotulla X09 )468-3420 <br />{ REGIONAL BOARD <br />PHONE <br />Central Valley Region <br />Mr. Lee Boggs (916)361-5740 <br />(') <br />NAME QUANTITY LOST (GALLONS) <br />Gasoline <br />UNKNOWN <br />i (a <br />UNKNOWN <br />DATE DISCOVERED IOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br />(A . 4 M 1 p 6 ® 9 y 0 - y ❑ <br />TANK TEST T ❑ TAW REMOVAL X] OTHER, drive off <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />OM 4.1 1 ®6 0 9 v O v <br />❑ UNKNOWN <br />❑ REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br />HAS DISCHARGE BEEN STOPPED 7 <br />❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br />® YES ❑ NO IF YES, DATE 0 ml 4 <br />MI 1 0 16 cj 9 r0 Y �] oTt�a u omatic sb �t off <br />SOURCE OF DISCHARGE <br />CAUSE(S) <br />❑' TANK LEAK UNKNOWN <br />❑ OVERFILL ❑ RUPTURE/FAILURE ® SPILL <br />❑ PIPING LEAK ® OTHER <br />❑ CORROSION ❑ UNKNOWN ❑ OTHER <br />w uI <br />CHECK ONE ONLY <br />N/A <br />❑ UNDETERMINED ❑ <br />,SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY <br />Z® <br />NO AG TAKEN <br />❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br />j cc N <br />❑ LEAK BEING CONFIRMED <br />❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br />O <br />❑ REMEDIATKOV PLAN <br />❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br />CHECK APPROPRIATE ACTIONS) <br />❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) <br />z <br />®Q <br />(SEEGACKMRoa=MM <br />❑ CAP SITE (CD) <br />❑ EXCAVATE &TREAT (ET) E]PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />Q <br />❑ CONTAINMENT BARRIER (CB)NO ACTION REQUIRED (NA) ❑ TREATMENT AT HOOKUP (HU) ❑ VENT SOIL (VS) <br />❑ VACUUM EXTRACT (VE) <br />❑ OTHER (OT) <br />Customer drove off with nozzle still in car. Filter blew out. Dealer took care <br />of clean up by using absorbent material to soak up spill. Dealer also replaced <br />g <br />filter. OES was <br />contacted. <br />. HSC 05 (I IAM <br />