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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ YES ® NO REPORT BEEN FILED? ❑ YES ® NO I HEAE81`CERTIFY TF{AT:1 AM A DESIGNATED GOVERNMENT EMPLOYEE AND THATJ:HAVE <br /> .AEPORTN.R.E'D THIS MATION TO LOCAL OFFICIALS PURSUANT TO 251 <br /> SECTION .80.7 OF <br /> REPORT DATE CASE u THE MEALTH AND SA'F?Y CODE <br /> 0119 M O DI 8 D8 Y 8 v <br /> SIGNED:: DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> David Brown (408) 984-6536 as agent for <br /> m 0 <br /> W REPRESENTING ® OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> 0 E] LOCALAGENCY OTHER Pacific Environmental Group, Inc. <br /> a <br /> ADDRESS <br /> 1601 Civic Center STREET Drive, Suite 202, Sante Clara, Ca 95050 ATE Z,P <br /> W NAME CONTACTPERSON PHONE <br /> Z� ARCO Petroleum Products ❑ UNKNOWN Mr. Kyle Christie o- ADDRESS (415 571-2434 <br /> wo- <br /> w Cc 2000 Alameda de j Pulgas, Suite218, SagITYMateo, CA 94402 STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> Q ARCO Station #2076 1LJS Enterprise, Inc 1 (209) 334-3678 <br /> ADDRESS <br /> 800 East KettlemqLane Lod�,y San Joaquin �a,HT,95240 ZIP <br /> W <br /> CROSS STREET TYPE OF AREA COMMERCIAL INDUSTRIAL RURAL TYPE OF BUSINESS <br /> ® ❑ ❑ R] RETAIL FUEL STATION <br /> State Highway 99 ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> LOCALAGENCY AGENCYNAME CONTACTPERSON PHONE <br /> Wwan Joaquin Local Health District Lori Cotulla (209) 468-3420 <br /> w REGIONAL BOARD <br /> PHONE <br /> as Central Valley Lee Boggs (916) 361-5600 <br /> w (�) NAME QUANTITY LOST(GALLONS) <br /> OW Waste Oil UNKNOWN <br /> O <br /> (2) <br /> y <br /> ❑ UNKNOWN <br /> w DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> 0 -19 -1 D —DI 8 Yj 8 y ❑ TANK TEST ® TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> W M M D D Y V <br /> ® UNKNOWN X❑ REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED? ❑ REPAIR TANKE] REPAIR PIPING ❑ CHANGE PROCEDURE <br /> p X❑ YES ❑ NO IFYES,DATE OMI9 M D —DI8 v 8 y ❑ OTHER remove tank <br /> W SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL <br /> CAUSE(S) <br /> ❑ TANK LEAK ❑ UNKNOWN GAL. ❑ FIBERGLASSXO OVERFILL ❑ RUPTURE/FAILURE <br /> U PIPING LEAK AGE YRS ❑ STEEL <br /> Cr. CORROSION ❑ UNKNOWN <br /> ® OTHER overfill ® UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> W W CHECK ONE ONLY <br /> a <br /> U ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> r- CHECK ONE ONLY <br /> Z N <br /> W¢a ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) [�] CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> cc <br /> 0 N ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 4 Z ❑ CAP SITE(CD) EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> 00 <br /> LU <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE 8 TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> F Bottom of excavation @ 12 feet has no hydrocarbons . <br /> Z <br /> W <br /> HSC 05(4/87) <br />