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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES LOCALAGENCY USE:ONLY <br /> YEE <br /> Q YES � REPORT BEEN FILED 7 0 YES ® NO p S IN:NkMA 1 TO COCAt flfF1CWS PElRSUANT IG SECTION 251807 OF <br /> REPORT DATE CASE as THEN >WO <br /> _... . <br /> 7 M Y Y <br /> SNGN SITE <br /> 0M <br /> NAME OF INDIVIDUAL FILING REPORT j PHONE SIOVATURE <br /> > Di M Hi ( 09 ) 468-3441 <br /> REPRESENTING a OWNER(OPERATOR a REGIONAL BOARD COMPANY OR AGENCY NAME <br /> g LOCAL AGENCY OTHER San Joaquin Local Health District <br /> a <br /> Q ADDRESS <br /> 1601 STREET E. Hazelton Avenue ,TY Stockton STATE CA U205 <br /> NAME CONTACTPERSON PHONE <br /> Dolly Madison/Lan endorf Baker 0 UNKN WN Mike Abbott (209 ) 946-0235 <br /> Cr <br /> ADDRESS <br /> w¢ 1426STREETS. Lincoln Street cRY Stockton SATE CA 95206 <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> Dolly Madison Lan endorf Baker Same 1 (209 ) 946-0235 <br /> ADDRESS S. Lincoln Street <br /> 1426 SXXKIKOI(�QXIM9% an Joaquin <br /> 8 STREET cc, StOCktOn � COUNTY 95206 <br /> W <br /> CROSS STREET TYPE OF AREA RA COMMERCIAL Q INDUSTRIALa RURAL TYPE OF BUSINESS RETAIL FUEL STATION <br /> Charter Way 0 RESIDENTIAL 0 OTHER FARM M OTHER <br /> tl LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> zwSan Joaquin Local Health Distr D. M. Hi ns (209 ) 468-3441 <br /> w <br /> w REGIONAL BOARD PHONE <br /> 5 Central Valley Region 1#5 A. Vorster (916 ) 361-5600 <br /> (�) NAME QUANTITY LOST(GALLONS) <br /> V UNKNOWN <br /> Gasoline <br /> UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED a INVENTORY CONTROL SUBSURFACE MONITORING Q NUISANCE OONDITIONS <br /> 21 M M o D Y y Q TANK TEST TANK REMOVAL Q OTHER <br /> F DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> ® UNKNOWN a REMOVECONTENTS Q REPLACE TANK ® CLOSE TANK <br /> w M M o o r r <br /> HAS DISCHARGE BEEN STOPPED Z REPAIR TANK ❑ REPAIR PIPING CHANGE PROCEDURE <br /> YES [:] NO IF YES,DATE M M ol 7 ol 8 YIA Y OTHER <br /> w SOURCE OF DISCHARGE TANKS ONLYCAPACITY MATERIAL CAUSE(S) <br /> q TANK LEAK [:�XUNKNOWN in nn GAL. Q FIBERGLASS F7 OVERFILL RUPTURE/FALURE <br /> Cr PIPING LEAK AGE YRS ®!STEEL CORROSION UNKNOWN <br /> a OTHER 1z UNKNOWN a OTHER a SPILL a OTHER <br /> W CHECKONEONLY <br /> CL <br /> [XI UNDETERMINED a SOIL ONLY O GROUNDWATER Q DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY <br /> z <br /> a SITE 1NVESTK3ATI0N IN PROGRESS(DEFINING EXTENT OF PROBLEM) CLEANUP IN PROGRESS Q SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> U a NO ACTION TAKEN O POST CLEANUP MONITORING IN PROGRESS 0 NO FUNDS AVAILABLE TO PROCEED 0 EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> aCAP SITE(CD) a R) <br /> EXCAVATE 6 DISPOSE(ED) Q REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION( <br /> L22 a CONTAINMENT BARRIER(CS) a EXCAVATE&TREAT(ET) a PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> a TREATMENT AT HOOKUP(I" 0 NO ACTION REQUIRED(NA) Q OTHER(OT) <br /> Pending soils results , further site assessment will be required to determine the nature <br /> and extent of contamination, as required by the appropriate regulatory agency. <br /> KSC os c4AM <br /> f <br />