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UAR/PROP 65_PRE 2019
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UAR/PROP 65_PRE 2019
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Entry Properties
Last modified
4/1/2020 11:52:55 AM
Creation date
11/2/2018 6:47:10 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
UAR/PROP 65
FileName_PostFix
PRE 2019
RECORD_ID
PR0231073
PE
2361
FACILITY_ID
FA0002064
FACILITY_NAME
7-ELEVEN INC. STORE #14117
STREET_NUMBER
2725
STREET_NAME
COUNTRY CLUB
STREET_TYPE
BLVD
City
STOCKTON
Zip
95204
CURRENT_STATUS
02
SITE_LOCATION
2725 COUNTRY CLUB BLVD
P_LOCATION
01
P_DISTRICT
003
QC Status
Approved
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SJGOV\rtan
Supplemental fields
FilePath
\MIGRATIONS\C\COUNTRY CLUB\2725\PR0231073\UAR PROP 65.PDF
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EHD - Public
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di <br />a q�-U3P- <br />T <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />FOR LOCAL AGENCY USE ONLY <br />REPORT BEEN FILED? <br />❑ YES NO ❑VES [:] NO <br />I HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br />DISTRIPUTION SHOW THE INSTPVQTION SHEET ON THE BACK PAGE OFTHIS FORM <br />! frpr i(r <br />`y G <br />REPORT DATE <br />CASES <br />Ai u Y <br />S N <br />DATE <br />NAME OF INDIVID AL FILING REPORT <br />PHONE <br />SI <br />(92s) 370-37� <br />p <br />w <br />REPRESENTING OWNERIOPEflATOR REGIONALBOARD <br />❑ <br />COMPANY OR AGENCY NAME <br />/ <br />F/ <br />¢ <br />8 <br />❑ LOCALAGENCY ❑ OTHER <br />¢ <br />/ <br />ADDRESS77 /)r"01��/`LV STC.-• � L.,/Z c4 NS13 <br />r/�' <br />JJ <br />cm STATE ZIP <br />srREer <br />NAME7713 <br />CONTACT PERSON <br />PHONE <br />w <br />J <br />Lo <br />,z J 4fQ ❑ UNKNOWN <br />—7 <br />w/� <br />a <br />w <br />¢ <br />y <br />ADDRESSle -7 /O <br />. (.�/, ll-r.�.ca.Y�YYO///"• / Imp 7Z <br />cRY STA ZIP <br />STREET V <br />o <br />F ILITY NAME (IF APPLIC L OP TOR PHONE <br />�(�/u �pyir7Jo��(._/a/ �� 124 163- 12sY <br />P: <br />/E�� / <br />/ <br />Ao'ToR�E7ss''j , 4 JT'�GiC7`�Oh <br />WL✓—L r4 Ll�vOt-� <br />.2 (•� REST LRY COU ZIP <br />w <br />y <br />CROSS S/TREET <br />U <br />Z <br />LOCALAGENCY AGENCY NAME <br />� f -�/� �/a�l5 <br />CONTACT PERSON <br />�� <br />PHONE <br />�o9'>y - <br />w <br />REGIONAL BOAR <br />PHONE <br />n a <br />s <br />( <br />n) NAME QUANTITY LOST (GALLONS) <br />w <br />U w <br />< <br />_/ . , ❑ UNKNOWN <br />/a r <br />w o <br />(2) <br />y <br />❑ UNKNOWN <br />GATE DISCOVERED <br />❑ INVENTORY O SOTBSRRFACE MONITORING E] NUISANCE CONDITIONS <br />HOO SCONK <br />w <br />0.1 7M DI 7v1v <br />TAw TEST TANK REMOy�ALNTROI <br />m <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />UNKNOWN <br />❑ REMOVE CONTENT CLOSE TANK& REMOVE ❑ REPAIR PIPING <br />W. <br />v <br />❑❑REPAIR TANK �0 CLOSE TANK 8 FILL IN PLACE CHANGE PROCEDURE <br />HAS DISCHARGEES❑BE <br />m <br />0 <br />NO YESDATE <br />�Y <br />REPLACE TANK OTHER <br />u v <br />¢❑ <br />OURCE OF DISCHARGE <br />TANKLEAK UNKNOWN <br />CAUSE(S) <br />❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br />rpn0 <br />❑ PIPINGLEAK ❑ OTHER <br />❑ CORROSION `�`11NKNOWN ❑ OTHER <br />/� <br />ww <br />CHECK ONE ONLY <br />❑ UNDETERMINED ❑ SOIL ONLY xGROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY IF <br />UNDERAYSUBMRTED ❑❑ POLLUTION CHARACTERIZATION <br />�y <br />❑ LEAK BEING CONFIRMED F7 PRELIMINARY SITE ASSESSMENT POST CLEANUP MONITORING IN PROGRESS <br />U <br />❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUPUNDERWAY <br />CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) <br />a <br />ISf wx rw ocTuel <br />❑ CAP SITE (CD) ❑ EXCAVATE& TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) [:]REPLACE SUPPLY (RS) <br />w <br />w < <br />❑ CONTAINMENT BARRIER (CB) ❑ NO ACTION REQUIRED (NA) ❑ TREATMENT AT HOOKUP (HU) ❑ VENT SOIL Ns) <br />¢ <br />VACUUM EXTRACT (VE) ❑ OTHER(OT) <br />n❑ <br />(�Zl -v GLtSCol,oc.d/ /GL.�r/I.,y q vilLO/'v�l%rlL..c/ O't <br />/0000- qal�c�Tie <br />Rsc aslenm <br />
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