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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 /> ��jj REPORT BEEN FILED 7 ❑ YES U NO I HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE . <br /> El YES JE3St NO DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OFTHIS FORM <br /> REPORT DATE CASS9 <br /> SIGNED DATE <br /> M NAME OF INDIVIDUAL FILING REPORT PHONESI RE <br /> > <br /> Gregory P. Stahl (209) 838-9888 1!! <br /> w REPRESENTING ❑ OWNERIOPERATOfl ❑ REGIONALSOARD COMPANY OR AGENCY NAME <br /> S ❑ LOCALAGENCY OTHER (� LOA13 taut round Zero Analysis, <br /> Inc. <br /> ADDRESS <br /> 1714 Main Street Escalon CA 95320 <br /> STREET LRY STATE ZIP <br /> i NAME CONTACT PERSON PHONE <br /> Valley Pacific Petroleum (2p9) 948-9412 <br /> ❑ UNKNOWN Dan Elmer <br /> C,5 ADDRESS <br /> w 166 Frank West Circle Stockton CA. 95206 <br /> STREET CITY STATE IP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR Valley Pacific PHONE <br /> o Woolse Oil Inc. Petroleum Services Inc. (209) 334-3969 <br /> ADDRESS 930 Victor Road (Hwy 12 ) Lodi CA. 95240 <br /> 0 <br /> 3lREE! CRY CWNTY P <br /> W <br /> � CROSS STREET <br /> w <br /> Hwy. 99 <br /> p LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> zw an Joaquin Co. Env. Health Dept. Dennis Catnaya5 (209) 468-3420 <br /> Ww� REGIONAL BOARD <br /> PHONE <br /> Central Valley Region James Barton (916 ) 255-3000 <br /> m (I) NAME QUANTITY LOST(GALLONS) <br /> UW <br /> Gasoline UNKNOWN <br /> Q� <br /> m� m <br /> MTBE UNKNOWN <br /> i DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING E::] NUISANCE CONDITIONS <br /> p 7. 1 7.1 0,1 3Y ❑ TANKTEST ❑ TANK REMOVAL OTHEFEnhanced Leak Detection est <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> u r r <br /> ® UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK 8 REMOVE E:]REPAIR PIPING <br /> o <br /> HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PUCE ❑CHANGE PROCEDURE <br /> YES ® NO IF YES,DATE ❑REPLACE TANK ©OTHERLeak Location & Repal <br /> M 4 C J Y Y <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ¢j ❑ TANK LEAK ® UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILUFS ❑ SPILL <br /> �� ❑ PIPING LEAK ❑ OTHER ❑ CORROSION © UNKNOWN ❑ OTHER <br /> Hn CHECKONEONLY <br /> O� ® UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> wZ ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> �y ® LEAK BEING CONFIRMED ❑ PRELIMINARYSITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTIONS) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> Iaff e.r wnoErAUI <br /> op ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY IRS) <br /> w <br /> w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> VACUUM EXTRACT(VE) ® OTHER(OT) UnknOWn at this time <br /> N <br /> f <br /> 2 <br /> W <br /> 8 <br /> XSC QS INS% <br />