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mminit <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES ' <br />„ <br />I YES [311 NO <br />REPORT BEEN FILED? <br />I YES k I NO 1 x7 I <br />FOR LOCAL AGENCY USE ONLY <br />1 HEREBY CEFMFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br />DISTRIBUTION SHOWN ON THE INSTRUCDON SHEET ON THE BACK PAGE OF THIS FORM. <br />REPORT DATE <br />0 ml 1 ml 1 501 9vI 9Y <br />CASE s <br />SIGNED DATE <br />>_ m <br />NAME OF INDIVIDUAL FILING REPORT <br />Keith A. Tallia <br />PHONE <br />(209) 754-1808 <br />S E . <br />/ <br />2 i- REPRESENTING I I OWNER/OPERATOR 1 I REGIONAL BOARD <br />I I LOCAL AGENCY Lxi OTHER Contractor <br />COMPANY OR AGENCY • <br />Oil Equipment Service L., cc ADDRESS <br />P.O. Box 950 San Andreas CA 95249 MEET CITY STATE ZIP <br />ill -, m <br />Z5 <br />NAME <br />I X I UNKNOWN <br />CONTACT PERSON PHONE <br />( ) <br />° < cL o. <br />cr) Lu cc <br />ADDRESS <br />STREET CITY STATE ZIP SITE LOCATION FACILITY NAME (IF APPLICABLE) <br />Waterloo Food & Fuel <br />OPERATOR <br />Paul Sidhu <br />PHONE <br />(209)466-5816 <br />ADDRESS <br /> <br />3032 E. Waterloo Rd. Stockton CA 95205 <br /> <br />STREET CITY COUNTY ZIP <br />CROSS STREET <br />Sutro IMPLEMENTING AGENCIES LOCAL AGENCY AGENCY NAME <br />San Joaquin Co. Env. Health <br />CONTACT PERSON /,..,_-_,tc ( 1 <br />Letitia Briggs <br />PHON _q c ,v) ye.,,,c5 . 5y, <br />( 20 468-3468 <br />REGIONAL BOARD <br />Central Valley Region <br />PHONE <br />(916)653-5791 , I SUBSTANCES DISCOVERY/ABATEMENT IN NAME QUANTITY LOST (GALLONS) <br />Gasoline IX I UNKNOWN <br /> <br />I I UNKNOWN <br />DATE DISCOVERED <br />0 ml 1 HI ODI 6DI 9y1 9y <br />HOW DISCOVERED I INVENTORY CONTROL I I SUBSURFACE MONITORING I NUISANCE CONDITIONS <br />I I TANK TEST IX I TANK REMOVAL I I OTHER <br />DATE DISCHARGE BEGAN <br />Ml ml Di DI VI Y1 X I UNKNOWN <br />METHOD USED TO STOP <br />I I REMOVE CONTENTS <br />DISCHARGE (CHECK ALL THAT APPLY) <br />XI CLOSE TANK & REMOVE I I REPAIR PIPING <br />I I CLOSE TANK & FILL IN PLACE I I CHANGE PROCEDURE <br />I OTHER <br />HAS DISCHARGE BEEN STOPPED? <br /> <br />Li ( 4„ <br /> NO IF YES, DATE (.11.4 1 I 6 1 <br />l <br /> <br />M Oj 'YI (Y <br />I I REPAIR TANK <br />I I REPLACE TANK SOURCE/ CAUSE SOURCE OF DISCHARGE <br />[ I TANK LEAK I I UNKNOWN <br />I I PIPING LEAK I I OTHER <br />CAUSE(S) <br />I 1 OVERFILL I I RUPTURE/FAILURE I <br />I I CORROSION 17 UNKNOWN I <br />I SPILL <br />I OTHER <br />U-I fif ma <br />6 <br />CHECK ONE ONLY <br />7 UNDETERMINED I I SOIL ONLY I I GROUNDWATER I I DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CURRENT I STATUS CHECK ONE ONLY <br />I I NO ACTION TAKEN I 1 PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED I I POLLUTION CHARACTERIZATION <br />I I LEAK BEING CONFIRMED n PRELIMINARY SITE ASSESSMENT UNDERWAY I I POST CLEANUP MONITORING IN PROGRESS <br />I I REMEDIATION PLAN I I CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) I I CLEANUP UNDERWAY REMEDIAL I ACTION CHECK APPROPRIATE ACTION(S) I I EXCAVATE & (SEE BACK FOR DETALS) <br />I I CAP SITE (CD) I 1 EXCAVATE & <br />I I CONTAINMENT BARRIER (CB) Li NO ACTION <br /> VACUUM EXTRACT (VE) IX-I OTHER pp <br />DISPOSE (ED) I I REMOVE FREE PRODUCT (FP) I I ENHANCED BID DEGRADATION (IT) <br />TREAT (ET) I I PUMP & TREAT GROUNDWATER (GT) I REPLACE SUPPLY (RS) <br />REQUIRED (NA) I TREATMENT AT HOOKUP (HU) I 1 VENT SOIL (VS) <br />TO be determined by PSA 1 COMMENTS I i • ,/,,, <br />& --P•6•LL-4 d l 'lb. Z.'k t: t..-5 _LA____, i - 7 i 61.-1-cv k_4, z_.7---C..C., ; <br />--t ---t ce-,44Le-d--4---2-z."---i, 4_,' t-, 1--; .... r <br /> <br />. 4- <br />HSC 058/901