UAR/PROP 65_PRE 2019 - Laserfiche WebLink

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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) I CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY DESIGNATED ❑YES ® � REPORT BEEN FLED? ❑YES a] NO REPORTED THIS NFORMATIONHEREBY CERTIFY THAT I AM A TO LOCAL OFFICIALS MENT EMPLOYEE AND THAT I PURSUANT URSUANT TO SECTION 251807OVE FJ THE HEALTH AND SA`TY CODE. REPORTDATE CASE• SIGNED DATE 1 M IO M p 4 B Y Y PHONE SIGN RE NAME OF INDIVIDUAL FLING REE PORT Jerry Cates ( 209) 462-1100 w REPRESENTING OWNEROPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCYN a E] LOCALAGENCY ❑ OTHER City of Stockton 0 a ADDRESS Ca 95206 1465 S. Lincoln Street WY Stockton VATS NAME CONTACT PERSON PHONE ¢ Cit of Stockton ❑ uNKNowN Jerry CAtes (209 ) 462-1100 Q<y ADDRESS 1465S. Lincoln Street Gm Stockton STATe CA 95206 s ReEr FACILITY NAME(IF APPLICABLE) OPERATOR PHONE victory Park Maintenance Building McClellan Terry (209 ) 944-8341 ADDRESS San CJoaquin95204 Stockton Argonne/Picardy ��gets cm NW yCROSSSTREET TYPE OF AREA ❑COMMERCIAL❑INDUSTRIAL❑RURAL TYPE OF BUSINESS ❑ RETAIL FUEL STATION Picardy EX]RESIDENTIAL ❑OTHER ❑ FARM In OTHER Government LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE 62 gW San Joaquin Health District (209 ) 468-3432 REGIONAL BOARD /PHONE � 1 ) (�) NAME QUANTITY LOST(GALLONS) UNKNOWN 9! gasoline 100 ❑ 2 (a m ❑ UNKNOWN DATEDISOOVERED HOWDISCOVERED M INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS 0.1 9 .12 p Sc H y 9y [CX] TANKTEST ❑ TANK REMOVAL ❑ OTHER DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) IOM 8 ml 2 o 0E 8 v 9 v ❑ UNKNOWN ® REMOVE CONTENTS ❑ REPLACE TANK E] CLOSE TANK HAS DISCHARGE BEEN STOPPED? ❑ REPAIRTANK ❑ REPAIRPPNG ❑ CHANGEPROCEDURE ❑ YES ❑ NO FYES,DATE IOM1 9 .1 2 .16 cj 8 Y19 Y ❑ OTHER SOURCE OF DISCHARGE TANKSONLYCAPACITY MATERIAL CAUSE(S) ❑ TANKLEAK [XA UNKNOWN 350 GAL. ``�❑ FIBERGLASS ❑ OVERFILL E] RUPTUREFAILURE 9. ❑ PIPING LEAK AGE YRS eL�l STEEL ❑ CORROSION ® UNKNOWN ❑ OTHER ® UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER wlu CHECKONEONLY � L UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CHECK ONE ONLY w i SITE NVESTIGATION IN PROGRESS(DEFINNG EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) U y ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ No FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATNES CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) ENHANCED BD DEGRADATION(IT) 8 F-1CAP SITE(CD) ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE6 TREAT(ET) ❑ PUMPB TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED INA) ❑ OTHER(OT) a H9C05(AIRJ)