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0 0 <br /> RELEASE RECORDING FORM Store Number 32190 <br /> IV Member Project# NA <br /> ELEvEn <br /> X 11mmediate Response <br /> Agency Release Report <br /> (Check all that apply) <br /> IMMEDIATE RESPONSE: Complete Part 1 for Immediate Response <br /> AGENCY RELEASE REPORT: Complete Part 2 for Agency Release Report <br /> Store Address: 4943 S. State RT. 99 Date: 5/23/2013 <br /> City/County: Stockton/San Joaquin Revision Date: <br /> State/Province: California SPM: <br /> THIS PART MUST BE COMPLETED . <br /> Fuel and water was discovered in the 87 turbine sump during an annual monitor certification being performed by Tanknology <br /> The fuel water mixture was contained to the sump and the liquid was removed at the time of the test. No soil or water <br /> impact. <br /> Date&Time of Incident:5/23/2013 —3:00 PM Date&Time Incident reported to Member: 5/30/2013 12:35 PM <br /> How was Member Notified and by whom: Email- Inspector <br /> Part 1 -Complete this section for IRs <br /> Tracking# from FM: NIA (if none,indicate N/A) <br /> Fuel spill (YIN): No Type of fuel: Gasoline <br /> Nozzle failure(YIN): No Equip. Mfg. NIA <br /> Customer error/inattention (YIN): No Vehicle Accident(YIN): No <br /> ID#Dispenser Affected: NIA Spill contained on pavement on site (YIN): No-Sum <br /> Spill Impacts (YIN): Storm.Sewer? No Retention Pond? No Waterway? No <br /> Amount and Disposition of Sorbent placed on Spill? None <br /> Local Agencies Involved : San_Joaquin County EHD on site for testing <br /> (Environmental,Fire,police,etc.) <br /> Local Agency Directions: <br /> Subcontractor Used/Phone# if applicable): None <br /> Park 2-.Complete this section for Releases Reported to A enctes <br /> Is Release Suspected Confirmed Reason for Reporting: <br /> (Only notify agency of suspected release when required) <br /> Member PM: <br /> Agency Name: <br /> (Environmental Agency,Water District,etc.) <br /> Agency Contact: Notification Timeline: <br /> Agency Incident#: (timeframe required for reporting) <br /> Reporting Notification Date: <br /> Notification Time: <br /> Member personnel making Notification: <br /> Agency Directions (if any): <br /> Updated Information: <br />