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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) I CONTAMINATION SITE REPORT <br />EMERGENCY MRT.,TBEECi)NFFFLN;JF? EMERGENCY SERVICES <br />I I YES [id NO 7 YES i 3c1x.No <br />FOR LOCAL AGENCY USE ONLY <br />1 HEREBY CERTIFY THAT HAVE DISTRIBUTED THIS INFOFIMATION ACCORDING TO THE <br />DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM. <br />REPORT DATE <br />Oq 4.1 2,, 5,,,I 9y1 6y <br />CASES <br />SIGNED : bATE <br />NAME OF INDIVIDUAL FILING REPORT <br />John Koch <br />PHONE <br />(510)675-6143 <br />SIGNATURE 4._.......2 REPORTED REPRESENTING rrjF OWNER/OPERATOR I I REGIONAL BOARD <br />I I LOCAL AGENCY I 1 OTHER <br />COMPANY OR AGENCY NAME <br />Shell Oil Products Company <br />ADDRESS <br />P. 0. Box 4023 Concord California 94524 sTREET ., STATE ZIP RESPONSIBLE PARTY NAME <br />Shell Oil Products Co I I UNKNOWN <br />CONTACT PERSON <br />Jeff Granberry <br />PHONE <br />(510)675-6168 <br />ADDRESS <br />P. O. Box 4023 Concord California 94524 STREET ury STATE ZIP SITE LOCATION FACILITY NAME (IF APPLICABLE) <br />Shell Station <br />OPERATOR <br />S. Griffin / D. Posey <br />PHONE <br />(209)599-4454 <br />ADDRESS <br />341 E. Main Ripon San Joaquin 95366 STREET CrTY COUNTY <br />ZIP <br />CROSS STREET <br />HWY. 99 IMPLEMENTING AGENCIES LOCAL AGENCY AGENCY NAME <br />San Joaquin Public Health Dept. <br />CONTACT PERSON <br />Ron Rowe <br />PHONE <br />(209 468-3420 <br />REGIONAL BOARD <br />Cnt. Valley Region Elizabeth Thayer <br />PHONE <br />(916) 255-3133 SUBSTANCES DISCOVERY/ABATEMENT INVOLVED NAME QUANTITY LOST (GALLONS) <br />Gasoline lxx UNKNOWN <br /> <br />[ I UNKNOWN <br />DATE DISCOVERED <br />0 N4I 4,1 2DI 401 9yl 6y <br />HOW DISCOVERED [ I INVENTORY CONTROL I I SUBSURFACE MONITORING I NUISANCE CONDITIONS <br />I I TANK TEST TANK REMOVAL L I OTHER <br />DATE DISCHARGE BEGAN <br />MI MI DI DI YI YI <br />K-1 UNKNOWN <br />METHOD USED TO STOP <br />[ I REMOVE CONTENTS <br />DISCHARGE (CHECK ALL THAT APPLY) <br />I I CLOSE TANK & REMOVE 437 REPAIR PIPING <br />I [ CLOSE TANK & FILL IN PLACE 1 I CHANGE PROCEDURE <br />gI4 OTHER over-excavated soil <br />HAS DISCHARGE BEEN STOPPED? <br />1?"1 YES 1 j NO IF YES, DATE O., 4,41 2,,, 40 9,,I 6, <br />I I REPAIR TANK <br />I REPLACE TANK SOURCE/ CAUSE SOURCE OF DISCHARGE <br />I I TANK LEAK Fc7 UNKNOWN <br />I I PIPING LEAK I I OTHER <br />CAUSE(S) <br />1 I OVERFILL I I RUPTUREJFAILURE I <br />I 1 CORROSION KI-1 UNKNOWN I <br />I SPILL <br />I OTHER <br />Leni w <br />6 c- <br />CHECK ONE ONLY <br />K1 UNDETERMINED I [ SOIL ONLY I I GROUNDWATER I I DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CURRENT STATUS CHECK ONE ONLY <br />NO ACTION TAKEN I I PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED I I POLLUTION CHARACTERIZATION <br />I I LEAK BEING CONFIRMED I )61 PRELIMINARY SITE ASSESSMENT UNDERWAY I I POST CLEANUP MONITORING IN PROGRESS <br />I I REMEDIATION PLAN 1 1 CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) I I CLEANUP UNDERWAY REMEDIAL I ACTION CHECK APPROPRIATE ACTION(S) FrIc. EXCAVATE & (sr:8 BACK Fat MIA'S) <br /> I CAP SITE (CD) EXCAVATE & <br />I I CONTAINMENT BARRIER (CB) Li NO ACTION <br />I I VACUUM EXTRACT (VE) Ticgmm(cm <br />DISPOSE (ED) I I REMOVE FREE PRODUCT (FP) I 1 ENHANCED RIO DEGRADATION (IT) <br />TREAT (El) 1 I PUMP & TREAT GROUNDWATER (GT) 1 I REPLACE SUPPLY (RS) <br />REQUIRED (NA) I I TREATMENT AT HOOKUP (HU) I I VENT SOIL (VS) <br />site investigation planned COMMENTS I DX46EN.-PetES bcTE7.---Tb 6154)1 1--L'fre----V AT <br />HSC 0518/901