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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/C TAMINATION SITE REPORT <br /> EMERGENCY NO STATE TANK ID: <br /> HAS STATE OFFICE OF EMERGENCY SERVICES <br /> i E:] VES rV�?NO REPORT BEEN FILED? f❑ YES ❑ <br /> NCAA I I <br /> REPORT116� DATE - LOCAL CASE <br /> (9N REGIONAL BOARD CASE k US EPA ID N <br /> `M "M 20 1 D 9Y '0 V <br /> NAME OF INDIVIDUAL FILING REPORT PNONE IG TURE <br /> J M ( ) - k Qe, c <br />- DREPRESENTING ❑ LOCALAGENCY OTHER COMPANY OR AGENCY E <br /> M DXOWNER/OPERATOR ❑' REGIONAL BOARD <br /> W ADDRESS <br /> P.O. Box WREpthrop, CA 95330 CITY STATE ZIP <br /> I > NAME (Property Owner) CONTACT PERSON - PHONE <br /> F <br /> GaO< <br /> [10 ❑ UNKNOWN ( ) <br /> a <br /> wJ ADDRESS - <br /> am P.O sT&pLxr 97, Lathrop', CA 95330 CITY STATE ZIP <br /> FACILITY NAME (IF APPLICABLE) _ OPERATOR PH <br /> Langston's James MONE <br /> o M. Langston ( 2ON ) 858-2470 <br /> OU ADDRESS 15615 Seventh Street, Lathrop; CA 95330 San Joaquin - <br /> J STREET CITY COUNTY - ZIP <br /> W TYPE OF AREA CROSS STREET [RCOMMERCIAL ❑INDUSTRIAL <br /> H TYPE OF BUSINESS RETAIL FUEL STATION <br /> H °LB Street F]RESIDENTIAL ❑RURAL ❑OTHER ❑UNKNOWN Q OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> __ San Joaquin County Environmental Health Car 09 ) 468-3468 <br /> W <br /> 2REGIONAL BOARD <br /> - <br /> 1990 <br /> WU <br /> WWI <br /> LL< TSCD <br /> ENVIRONMENTAL HEI�TH ) <br /> W CAS 4 (ATTACH EXTRA SHEET IF NEEDED) NAME QUANTITY LOST (GALLONS) <br /> UO <br /> Z,¢> ltl I - Leaded Gasoline - q �Q UNKNOW <br /> fJ <br /> O <br /> Ln UNKNOW <br /> DATE GDISCOVERED HOW DISCOVERED . ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING - <br /> > 6 - OY [n ROUTINE MONITORING TANK C]C] NUISANCE CONDITIONS E] OTHER: ' <br /> M <br /> WW <br /> DATE DSC�A RG^ BEC'.AN 0 _ _ METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) . <br /> uH M M D' -0 y Y Y ❑. UNKNOWN REMOVE CONTENTS ❑ REPLACE TANK ❑CLOSE TANK <br /> �Q HAS DISCHARGE BEEN STOPPED? 0 6 -1 5 9 0` _3 REPAIR TANK ,; ❑REPAIR PIPING ❑CHANGE,PROCEOURES <br /> `XES ONO IF VES, DATE Mi Mi DI DI Y Y F-1 OTHER <br /> SOURCE(S) OF DISCHARGE ACITY GAL CA USES) <br /> j ❑TANK LEAK UNKNOWN ❑OVERFILL ❑CORROSION <br /> < - AGE I I W YRS. UNKNOWN <br /> W ❑PIPING LEAK.,. MATERIAL ?'. 1��1 RUPTURE/FAILURE ❑SPILL <br /> U - - ❑STEEL ❑ FIBERGLASS <br /> m F-1 OTHER ISPECIFYI ❑OTHER <br /> _]UNKNOWN ❑OTHER <br /> RESOURCES AFFECTEDWATER SUPPLIES AFFECTED - _ <br /> YES NO THREATENED ` UNKNOWN <br /> YES NO ENEO KNOWN WELLS <br /> F AIR IVAPORI - _ ❑. Y- .'.• _.❑ ❑ PUBLIC DRINKING ❑ r, ^ <br /> W SOIL (VADOSE ZONE) -A WATER IJ L_I <br /> LL ' GROUNDWATER ❑ - ❑ ❑ PRIVATE DRINKING ❑. ❑ 0.� .{-1 <br /> <Y ' ❑ 1❑��V1 ❑ WATER <br /> m� SURFACE WATER OR STORM DRAIN ❑ " ` ❑ .. - INDUSTRIAL ❑ Q '❑ <br /> UI- BUILDING OR UTILITY VAULT ❑ ❑ r ❑ AGRICULTURAL ❑ -❑ ❑ <br /> p< _OTHER (SPECIFY) - ❑ ❑ 0 ❑ -OTHER(SPECIFY) ❑ ❑ _ ❑ <br /> W <br /> W <br /> S -GROUNDWATER BASIN NAME <br /> UNKNOWN <br /> COMMENTS: Leakage resulted from testing performed on 6/14/90 by a Certified Tester. <br /> z Owner was not notified of any condition of tank upon Tester leaving job. Loss was <br /> detected upon standard daily monitoring on 6/15/90. <br /> COMPLETE AND ATTACH A CLEANUP TRACKING REPORT IF ANY CLEANUP WORK OR PLANNING HAS STARTED •Hsc as (10,851 <br />