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1 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELtAS (LAK)1 CONTAMINATION �+ <br /> EMERGENCY } T HAS STATE OFFICE OF EMERGENCY SERVICES `',TE B�PORT <br /> ❑ <br /> YES F10 .SEPORTBEENFILED9 w ..c ( �QH FEB;5777 <br /> []YEs No t + ey HEE BY C@RTIYTHT)AA«U�,«1.N <br /> TAEPORTDA7E AMOEd 00VFANM <br /> CASEN, FORTIONT <br /> YE Ni EMPLdY�5CATNIDON,TH2A5T180f I#AO1�F lJ <br /> H <br /> 2 . 8 8 <br />! M NAME OF INDIVIDUAL FILING REPORT SK3MED':: <br /> tr �r " PHONE- �, DATE <br /> D4 M. HIINSON y ll SIGNA <br /> REPRESENTINO l 2D�468-3441' <br /> 6' ❑ OWNEWOPEAATOR ❑ REGIONAL 90ARD COMPANY OR AGENCY NAME <br /> ¢ LOCAL AGENCY OTHER 1` J <br /> ¢ ADDRESS <br /> AN"JOA LOCAL '-HE - <br /> ALTH DISTRICT <br /> 1601 E. HAZELTON AVE. <br /> NAME <br /> e R r�rr STOCKTON t er�Te CA 95205 <br /> CONTACTPERSON : PHONE i t <br /> ¢ COLBERG . INC, x <br /> ❑ uniKNowni. W.H. COLBERG _` t09 )466-7041 <br /> I ADDRESS <br /> a 401 N N. STOCKTO4rnotrSTREET .:. r <br /> �m, s r <br /> FACILITY NAME(IF+4PPLICAALE) - � � STOCK CA 95203., OPERATOR stxtE' , p <br /> COLBERG> - INC. + PHONE <br /> ,` CULBERG r INC, ; '"` X209 )466-7041 <br />. � ADDRESS i.,. <br /> 401 N': ` STOCKTON STREET. �' , . <br /> 'STOCKTON, SAIV JOAQi1TN 9520:3 <br /> w CROSS STREET TYPE OF AREA <br /> FREMONT & LINDSAY COMMERCIAL ❑INDUSTRIAL ❑RURAL TYPE OFBUSINESS k2TAILFUELSTATION <br /> RESIDENTIAL ❑OTHER SHIP YARD <br /> LOCALAG£NCY FARM OTFIER <br /> to AGENCY NAME CONTACT PERSON 1 <br /> SAN JOA UIN LCOAL HEALTH DIST D M HINSON PHONE <br /> 11 $09 )468-3441 <br /> , REGIONAL BOARD <br /> CENTRAL VALLEY--SACRAMENTO PHONE <br /> (1) NAME A VURSTER V16 )361-5670 <br /> �� GASOLINE; REGULAR LEADED OUANTITYLOST(GALLONS) <br /> + (2) UNKNOWN <br /> DATE DISCOVERED�• i;.. HOW DISCOVERED ❑ UNKNOWN <br /> ❑ iNVENTORY CONTROL ❑ SUBSURFACE MDNITORWG ❑ NUISANCE CONDITIONS <br /> D ' o Y 6 y L_J TANK TEST TANK REMOVAL 'f� #`�❑ A„ . <br /> DATE DISCHARGE BEGAN . dTHER <br /> USED TO MP 69(*ARGE(CHECK ALL THAT APPLY) <br /> UA I�vM u t 3. <br /> o o v L p UNKNOWN r (,❑ REMOVECONTENTS %t❑ <br /> HAS DISCHARGE BEEN REPLACE TANK . �'CLOSE <br /> TANK <br /> D? r r <br /> _ Y f 7 ., r,�r? '❑ REPAlR TANK ❑ REPAIR PIPING <br /> �r I, r ❑ CHANGE PROCEDURE <br /> NO IF YES,DATE: (L 5 11 D 6 0' 8xY :6 ETHER 4 <br /> YES ❑ R <br /> r SOURCE OF DISCHARGE Y - <br /> j a 7ANltSONLYlC4PACi7Y M F.MATERIAL CAUSES) <br /> ❑ TANK LEAK EX UNKNOWN r <br /> :�DQ_ GAL r7' ❑>FIBEIiGLA$3 <br /> ❑ PIPINGLEAK 't'I ? = AGE. ,:; �� Yp + t3TEL "' ` ❑ OVERFILL a RUPTUREfFAL URE <br /> ❑ :n <br /> OTHER d: UNKNOWN '' ❑ O7}IER " ❑ UNKNOWN <br /> CORFiDSION <br /> NOWN' <br /> ..,r, <br /> W CHECK ONE ONLY <br /> y LL Q OTHER <br /> ® UNDETERMINED' <br /> SOIL <br /> ❑ Q. GRbUNDWATEF( ❑ DRINKING VIIATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> Z In <br /> FTAEATMENT"AT <br /> NLY"NVESTIGATION IN PROGRESS(OEFINIh1GEIfTENTOFpR06LEM I ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETEDOR UNNECESSARY) <br /> TION TAKEN ❑ P497 CLEANUPMONITORING IN PROGRESS ND FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> PRIATE ACTIONS)(SEE BACK FOR DETAILSITE(CD) ExCA1/ATE BDISPD§E EDINMENT BARRIEA(CB) s ( ) - 1❑ REMOVE FREE PRODUCT jFP) ❑ ENHANCED 816 DEGRADATION(IT) <br /> ❑ EXCAVATE R TREA?(ETj PUMP 8 TREAT 6ROUNDWATEA(GT) ❑ REPLACE SUPPLY(RS) <br /> MEN f AT HbOKUP(HU) ❑ NO ACTION REOUtRED(!NA) r, ❑ OTHER(07) <br /> 77 <br /> f v' <br />