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1 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE 1LtAX)4&JA%IG4 SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENCTA a8i <br /> ¢E *+ EE�iigq11tt� <br /> EMPLOYEE ANDJHAT'rjr�HAV�:' <br /> ❑ YES ® NO REPORT BEENFILED7 ®YES ❑ NO pEEPORTEQ TREBYr �1f (� 1l3iPQ ANT Q SEGTWN 251 0.7 OF. <br /> REPORT DATE CASES 7NEHEALTHAN0SAF ( rsER.. <br /> 0,1 6,1 0 1,1 9yi 1113 3 SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE I SIGNA URE <br /> Elaine Lavine (415) 571-2482 <br /> REPRESENTING OWNER(OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> a LOCAL AGENCY ❑ OTHER ARCO Products Company <br /> W <br /> °C ADDRESS <br /> P.O. Box 5811 ST�tn:Env.Compl.Dept. San Mateo CA SATE 94402 ZP <br /> W NAME CONTACTPERSON PHONE <br /> ARCO Products Company ❑ UNKNOWN Elaine Lavine (415) 571-2482 <br /> R a ADDRESS <br /> P.O. Box 5811 Attn: Env.Compl .Dept. San Mateo CA 94402 <br /> cr <br /> STREET CRY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> o ARCO Facility # 595 Mercedes Acosta ( 20� 931-5976 <br /> U ADDRESS <br /> .� 6100 N. Hwy 99 Stockton CA 95205 <br /> STREET CRY COUNTY ZIP <br /> CROSS STREET <br /> Hammer Lane <br /> Z <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> `� <br /> zw <br /> San Joaquin Local Health Lori Cotulla 09 )468-3420 <br /> W z <br /> w0 REGIONAL BOARD PHONE <br /> Central Valley Region Lee Boggs X16 )361-5600 <br /> h (1) NAME QUANTITY LOST(GALLONS) <br /> i Ow Gasoline UNKNOWN <br /> J <br /> m Z (2)( <br /> N <br /> ❑ UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> M M D D Y O Y <br /> © TANK TEST ❑ TANK REMOVAL / OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> MI M1 DI DI Y1 Y1 UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> O HAS DISCHARGE BEEN STOPPED Z ❑ REPAIR TANK E:] REPAIR PIPING E:] CHANGE PROCEDURE <br /> 8 no ,mown discharge � <br /> o ❑ YES ❑ NO IF YES,DATE M M D D v v [n OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> L) F7TANK LEAK n/a F7 UNKNOWN ❑ OVERFILL E] RUPTURE/FAILURE E::] SPILL <br /> 8 V ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> W <br /> a CHECK ONE ONLY n/a <br /> 6�j ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> � aa <br /> W N ❑ NO ACTION EN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> cc <br /> M ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) [:] REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> (SEE BACK FOR DET" EJ <br /> o Q ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) THUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ® OTHER(OT) C e A h a 1 aw <br /> w Tanis test failure. Product lines are tight and leak detector wording <br /> o properly. Uncover vent & vapor line of tank to find problem. <br /> L) OES & San Joaquin Haz Mat notified. (Carol Oz ) <br /> NSC os n veil <br />