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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES pFOR LOCAL`AGENCY USE ONLY <br /> : <br /> VES ® NO <br /> REPORT BEEN FILED? 1 HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TOTHE <br /> `IES- NO <br /> QISR118UTK)N SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OFTHIS FORM <br /> REPORT DATE CASES <br /> QM '.1 24 1 9 N SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE A <br /> Keith A. Tallia ( 209) 754-1808 <br /> REPRESENTING Q OWNER/OPERATOR Q REGIONALBOARD COMPANY OR AGENCY NAWV <br /> S Q LOCALAGENCY [E OTHER Contractor Oil Equipment Service <br /> w ADDRESS <br /> P.O. Box 950 San Andreas CA 95249 <br /> 9 Aeff CT' STATE ZIP <br /> W NAME CONTACT PERSON PHONE <br /> ® UNKNOWN ( ) <br /> H i ADDRESS <br /> w <br /> STREff CITY STATE nP <br /> PERATOR PHONE <br /> FACILITY NAME(IF APPLICABLE) O <br /> $ Sunnyside Produce Mike Manser ( 204 794-2720 <br /> a ADDRESS <br /> g 8960 W. Walnut Grove Rd. Thornton San Joaquin 95686 <br /> w STREET CRY MIJIWY ZIP <br /> y CROSSSTREET <br /> I-5 Freeway <br /> U. LOCAL AGENCY AGENCY NAME CDNTACTPERSON PHONE <br /> w San Joaquin Co. Env. Health Letitia Briggs ( 20S) 468-3468 <br /> H <br /> � REGIONAL BOARD PHONE <br /> ` Central Valley Bret Wyckoff ( 916 653-5791 <br /> w (T) NAME QUANTITY LOST(GALLONS) <br /> w <br /> 4w Gasoline UNKNOWN <br /> m� m <br /> y Diesel ® UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED O INVENTORY CONTROL SUBSURFACE MONITORING O NUISANCE CONDITIONS <br /> 0 1.1 2 1 D 9Y 9Y O TANK TEST TANK REMOVAL O OTHER <br /> mDATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> © UNKNOWN O REMOVE CONTENTS O CLOSE TANK REMOVE O REPAIR PIPING <br /> M1 4 01 Y1 Y <br /> 8 HAS DISCHARGE BEEN STOPPED 1 O REPAIR TANK O CLOSE TANK&FILL IN PLACE O CHANGE PROCEDURE <br /> o ® YES O NO IF YES,DATE a (3 Y Q REPLACE TANK O OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> F TANK LEAK ® UNKNOWN O OVERFILL 0 RUPTURE/FAILURE a SPILL <br /> mO O PIPING LEAK OTHER CORROSION [:X UNKNOWN O OTHER <br /> yw CHECK ONE ONLY <br /> O O UNDETERMINED E:] SOIL ONLY ® GROUNDWATER O DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> iZ O NO ACTION TAKEN Q PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED 0 POLLUTION CHARACTERIZATION <br /> aF O LEAK BEING CONFIRMED ® PRELIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS <br /> O m O REMEDIATION PLAN 0 CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) a CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTIONS) 0 EXCAVATE&DISPOSE(ED) O REMOVE FREE PRODUCT(FP) O ENHANCED BIODEGRADATION(IT) <br /> ISff e.r.R RYI o[TNHI <br /> a 0 <br /> OQ O CAP SITE(CD) EXCAVATE&TREAT(ET) E] PUMP&TREAT GROUNDWATER(GT)Q REPLACE SUPPLY(RS) <br /> w< O CONTAINMENT BARRIER(CB) NO ACTKIN REQUIRED INA) TREATMENT AT HOOKUP(HU) O VENT SOIL(VS) <br /> E] VACUUM EXTRACT(VE) ® OTHER(OT) To be determined by PSA <br /> N <br /> F <br /> Z <br /> W <br /> 1 <br /> NSC os IA'>rol <br />