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UNDERGROUND STORAGE TANK UNAUTHORIZEITRELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL'AGENCY>USE' <br /> REPORT BEEN FILED? <br /> ❑ YES FX� NO ❑ YES ❑ NO EBYC <br /> CERTIFYTHAT 1 HAVEDISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> �TRIBUT(ON SWPWN�ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT DATE �O � <br /> ES xS [[¢¢ <br /> OM 7M� 3 scwEa DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> } Ruth Bulmer (602 ) 530-5113 <br /> Co <br /> REPRESENTING ® OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> 2 ❑ LOCAL AGENCY ❑ OTHER Circle K Stores Inc. <br /> WX ADDRESS <br /> P. O. Box 52084 Phoenix AZ VV9';fV 85072 <br /> STREET CITY STATE ZIP <br /> LU NAME CONTACT PERSON PHONE <br /> zr- Circle K Stores Inc. ❑ UNKNOWN Myron Smith ( 602) 437-0600 <br /> a a ADDRESS <br /> U) <br /> cc P. O. Box 52084 Phoenix AZ 85072 <br /> STREET CITY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> o Circle K Store #8671 Circle K Stores Inc. ( 602 437-0600 <br /> ADDRESS <br /> ° 8606 Thornton Ro Stockton San Joaquin 95209 <br /> LU ET CITY COUNTY ZIP <br /> n CROSS STREET <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> wLu San Joaquin County EHD M van ( 209 468-343* <br /> w REGIONAL BOARD PHONE <br /> as // <br /> � 1 ) <br /> LU (�) NAME QUANTITY LOST(GALLONS) <br /> 0 <br /> z, Premium unleaded gasoline ® UNKNOWN <br /> j z (2) <br /> ❑ UNKNOWN <br /> r DATE DISCOVEREDHOW DISCOVERED <br /> Z ❑ INVENTORY CONTROL SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Lij <br /> w 0 MI 7m, <br /> M 3 DI ODI 9N 6 Y ❑ TANK TEST ❑ TANK REMOVAL g OTHER line test -AVWQ4L <br /> F- <br /> a DATEDISCHARGE BEGAN <br /> M METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> W M M D D Y Y EM UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE E]REPAIR PIPING <br /> 0 HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> U <br /> 0 ❑ YES ❑ NO IF YES,DATE MI D V Y ❑REPLACE TANK OOTHER shut down premium sy tem <br /> MI D <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> w <br /> ❑ TANK LEAK f:] UNKNOWN ❑ OVERFILL O RUPTUREIFAILURE ❑ SPILL <br /> U)O ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> w w CHECK ONE ONLY <br /> U)D- <br /> v UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> W <br /> cc CC w LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY a POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> J ISEE BACK EOH DE to ) <br /> z ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> o O <br /> Cr c ❑ CONTAINMENT BARRIER(CB) E:] NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) OTHER(OT) to be determined <br /> z this is only a suspected release. Circle K service will investigate <br /> LU <br /> and make repairs. SECOR Environmental will determine if actual leak <br /> 0 occurred and decide appropriate remedial activities if needed. <br /> HSC 05(fi9D) <br /> CC <br />