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06/05/2008 09:56 FAX 9258425660 CHEVRON PRODUCTS COMPANY IM002 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES O '4OGAL�AC�Sl�CY,US�ONLY <br /> ❑Yes ®NO REPORT BEEN FILED? ❑Yes Z No I HE 9Y CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE°AND THAT I <br /> REPORT00 THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7OF:. <br /> REPORT DATE CASE# THE HEALTH ANbaSaETY GODS." <br /> 6/3/2008 <br /> "SIGNED ; DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> Eric Munns (209) 858-1082 -, <br /> mo REPRESENTING COMPANY OR AGENCY NAME <br /> 'L ❑LOCAL AGENCY ❑REGIONAL BOARD Chevron Products Company <br /> 0 Z OWNER/OPERATOR ❑OTHER <br /> w ADDRESS <br /> 16956 Harlan Rd. Lathrop, CA 95330 <br /> STREET CITY STATE ZIP <br /> w NAME CONTACT PERSON PHONE <br /> ti Chevron Products Company ❑Unknown "Permit Desk" (925) 842-9002 <br /> Z <br /> ADDRESS <br /> W a PO Box 6004 San Ramon, CA 94583 <br /> STREET CITY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> Chevron#96171 Chevron Stations, Inc. (209) 477-4294 <br /> -7 <br /> a ADDRESS <br /> 0 6633 Pacific Ave. Stockton San Joaquin 95215 <br /> STREET CITY COUNTY ZIP <br /> CROSS STREET <br /> W. Benjamin Holt Dr. <br /> LOCAL AGENCY AGENCY NAME PHONE <br /> 0 <br /> Z w San Joaquin County-Environmental Helth Dept. (209) 468-3420 <br /> W U <br /> w� REGIONAL BOARD /PHONE <br /> tu <br /> (1) NAME QUANTITY LOST(GALLONS) <br /> w o <br /> U w 87 octane gasoline 2 ❑ Unknown <br /> h of (2) <br /> ti Z ❑ Unknown <br /> Z DATE DISCOVERED HOW DISCOVERED ❑Tank Test ❑Tank Removal ❑Nuisance Conditions <br /> W 6/3/2008 ❑Inventory Control ❑Subsurface Monitoring ®Other <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> > 6/3/20®8 ❑Remove Contents ❑Close Tank <br /> ❑ UNKNOWN ❑Repair Tank ❑Change Procedure <br /> HAS DISCHARGE BEEN STOPPED? <br /> N ❑ Replace Tank ®Other <br /> o ®YES ❑ NO IF YES,DATE 6/3/2008 ❑ Repair Piping <br /> iD w SOURCE OF DISCHARGE CAUSE(S) <br /> OCD <br /> N ❑Tank Leak ❑Piping Leak ❑Unknown Z Other ❑Overfill ❑Corrosion ❑Rupture/Failure ❑Unknown ❑Spill Z Other <br /> W w CHECK ONE ONLY <br /> ma <br /> ❑Undetermined ❑Soil Only ❑Groundwater ❑ Drinking Water—(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> zU, ElNo Action Taken Z Case Closed(Cleanup Completed or Unnecessary) <br /> Ua ❑Leak Being Confirmed ❑Pollution Characterization <br /> N ❑Remediation Plan ❑Post Cleanup Monitoring in Progress <br /> ❑Preliminary Site Assessment Workplan Submitted ❑Cleanup Underway <br /> ❑Preliminary Site Assessment Underwa <br /> CHECK APPROPRIATE ACTION(S) <br /> 0 0 [ICap Site(CD) ElExcavate&Treat(ET) ElTreatment At Hookup(HU) Z Other <br /> LU I= ❑Contamination Barrier(CB) Z No Action Required(NA) ❑Enhanced Bio Degradation(IT) <br /> W a ❑Vacuum Extract(VE) ❑Remove Free Product(FP) ❑Replace Supply(RS) <br /> ❑Excavate&Dis ose ED ❑Pump&Treat Groundwater(GT) ❑Vent Soil(VS <br /> y At approximately 15:00, customer was attempting to fill up their vehicle at dispenser#5 and the nozzle started dispensing as <br /> W soon as it was activated.......about 1-2 gallons of product was spilled. Employee hit the emergency shut-off button and <br /> contained spill with absorbent materials. Product was fully contained,with no storm drain contact,and appropriately cleaned <br /> 0 <br /> 0 up. <br /> UN-028-1/2 www.unidocs.org Rev.10/31/06 <br />