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• <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)I CONTA<MINAUM SITE REPORT <br /> EMERGENCYHAS STATE OFFICE OF EMERGENCY SERVICES ;FOR:LOCALAGENCY USE ONLY'.':"...i <br /> REPORT BEEN FILED? ❑Yes ®No JHEREBY-C9R1*''fHKTIMAAMSIGMIM-0 aR`9MWMFtANbTMTININIE <br /> 0 Yes ®No ;. Ri14t I!�S''> ? to LbCJu-4)FRCw.i?!MYAN3`:Tp:.aECtI K Z lealr dF-- <br /> REPORTDATE CASE M <br /> .::.... ... <br /> -- ----- ._-:.:::...:rc.:e.. pax;=. �::...:.: ...... ...... _..... <br /> 5/31/2008DATE <br /> �+ NAOF NDNDUAL FILNG REPORT PHONE SaC4TURE <br /> Eric MtlnnsME 209 858-1082 _ <br /> REPRESENTING COMPANY OR AGENCY NAME <br /> o <br /> z <br /> ❑LOCAL AGENCY ❑ RFG40NAL BOARD Chevron Products Company <br /> o ®OWNEMPERATOR [:1 OTHER <br /> ADDRESS <br /> 16956 Harlan Rd. Lathrop, CA 95330 <br /> STREET CnY STATE 23P <br /> MAW CONTACT PERSON PHONE <br /> Chevron Products Company p unit "Permit Desk" 925 842-90(12 <br /> a 0. ADDRESS <br /> PO Box 6004 San Ramon, CA 94583 <br /> of STREET cRy STATE zr <br /> FACILITY NAME OF APPLICABLE) OPERATOR PHO <br /> NE 0 <br /> Chevron#96171 Chevron Stations, Inc. 209 477-4294 <br /> ADDRESS <br /> o b633 Pacific Ave. Stockton San Joaquin 95215 <br /> STREET crry counrrr a>' <br /> w - <br /> m CROSS STREET <br /> `lV.Benjamin Holt Dr. <br /> LOCAL AGENCY AGENCY NAME PHONE <br /> San Joaquin County-Environmental Helth Dept (209) 468-3420 <br /> f <br /> z PHONE <br /> w a REGIONAL BOARD <br /> (1) NAME QUANTITY LOST(GALLONS) <br /> v 87 octane gasoline 4 ❑ uwknom <br /> M + <br /> ❑ Unkra <br /> rL DATE DISCOVERED HOW DISCOVERED ❑Tank Test Tank RerrxNal LI Nuisance Condition <br /> l 5/31/2008 ❑I central ElsutYsu Lace mcnitnri 003w <br /> W ,_ <br /> � [HATE DISCHARGE BEGAN <br /> USED TO STOP DISCHARGE(CHECK ALL T1il1TAPPL <br /> 5/31/2008 ❑Renwe Contents Q Close Tank <br /> w <br /> ❑ UNKNOWN Q Repair Tank ❑Charge Procedure <br /> C) <br /> HAS Dd9"RGE BEEN STOPPED? R.O.Tank ®00ier <br /> > o El YES ❑ NO IF YES,DATE 5/31/2008 ❑ Repar pin-g <br /> a m SOURCE OF DISCHARGE CAUSE(S) <br /> OU ❑Tank Leak ❑ ipi <br /> Piping Leak i]Unkown n ®Other L]Overfdf ©Corrosion [IRupturerFaDwe El UnknOWD ElSpill ®00wr <br /> c� CHECK ONE ONLY <br /> 1— tu w <br /> o E1 UrKWtermwled ❑Sal n9 <br /> 0 <br /> �y Q Groundwater ❑Drinking Water-(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> �- ❑No Action Taken ®Case Closed(Cleanup Completed or Unnecessary) <br /> z w ❑Leak Being Confrrrred ❑Pollution Characterization <br /> o a ❑Remediation Plan ❑Post Cleanup Monitoring In Progress <br /> =.0 <br /> ❑Preliminary Site Assessment Workpfan Submitted ❑Cleanup Underway <br /> _ ❑Prefirninary Sloe Assessment Underway <br /> c� <br /> CHECK APPROPRtATEACTION(Sy <br /> El Cap Sipe(CD) [I Excavate&Treat(ET) [ITreatrrlent At Hookup(HL)) ®Other <br /> � ❑Contarnmation Barrer(CB) ®No ActbDn Required(NA) ❑Enhanced Bio Degradation(IT) <br /> Q o <br /> wc a ❑u <br /> Vacln Extract(VE) E]Remove Free Product(FP) ❑Replace Supply( ) <br /> -�- ❑E=wxte& ❑Purnp&Treat Groundwater G ❑Vent Soil <br /> At appmirnateiy 16:15,customer was filling up vehicle and nozzledidn't shut off when tank was frill..._....about 4 gallons of <br /> rz product was spilled. Employee hit the emergency shut-off button, called total fire department for asststance and oontamed <br /> spill.with absorbent materials. Product was contained,with no storTn drain contact,and appropriately cleaned up. <br /> 0 0 <br /> c� U <br /> �r Rev.1631/06 <br /> UN-02r-In wwrrJ<L1fDcLor'g <br />