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9� ' <br /> UNDERGROUND STORAGE I NK UNAUTHORIZED RELEASE (LEAK)/ OONTAMINATION SI? '--:'TE T <br /> EMERGENCY AEPOo <br /> HAS STAOFFICE OF EMERGENCY SERVICES : FOR LOCAL AGENCY USE ONLY <br /> ❑ YES ® NO REPORT BEEN FILED? <br /> YES NO I AEREBY CERTIFY THAT IAMA:DESIGNATED GOVERNMENT'EMPLG'YEE ANOIHAZ E <br /> ❑ © REPORTED THIS INFORMATION:TO LOCAL OFFICIALS PURSUW.TO SECT{ON 25t807:OF <br /> REPORT DATE CASES THE HEAL AND SAM_CODE. <br /> 0 � �M( 3d l d 9 rl 0 r slcNeD <br /> NAME OF IIVDiV10UAL FILING REPORT PHONE GATE <br /> SI TURF <br /> Jerry Middleton (415) 946-1055 <br /> w REPRESENTING ® OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> O LOCAL AGENCY <br /> ❑ OTHER The MARK Group, Engineers & Geologists, Inc. <br /> ADDRESS <br /> 3480 Buskirk Avenue, Suite 120 Pleasant Hill CA 94523 <br /> SYREE'T C" sT�TE <br /> w <br /> NAME CONTACTPERSON ZIP <br /> ZrI Mid Cal Leasing, Inc. PHONE <br /> Q UNKNOWN Mr. Edward J. Gotelli (Z09 )465-3609 <br /> w a09 <br /> w <br /> ADDRESS <br /> North-Broadway sTnR Stockton STATE CA x,9520 <br /> FACILITY NAME(IF APPLICABLE) OPERATOR <br /> PHONE <br /> Vacant Industrial property jMid Cal Leasing, Inc. X109 )465-3609 <br /> ADDRESS <br /> w <br /> 1649 East Channel Street Stockton San Joaquin 95205 <br /> CROSS STREET am COuNTr MP <br /> Between Eugenia Street <br /> aand <br /> x�Locust Street <br /> zw aAAJOaquin County Public eaith ServicesNTACTPERSON PHONE <br /> LU IJ Envirgnm h 11 <br /> a< REGIONAL BOARD Ca rgl Oz U9468-3420 <br /> PHONE <br /> Central Valley Region ) <br /> s <br /> d w (} E QUANTITY LOST(GALLONS} <br /> yZ' <br /> d Q UNKNOWN <br /> m ZI <br /> f ❑ UNKNOWN <br /> Z DATE DISCOVERED HOW DISCO REO ❑ 4vFNTORY CONTROL ❑ SUBSURFACE MONITORNG Q NUISANCE CONDITIONS <br /> `(i 1 O 2 a 9r 0 r ❑ TANK TEST © TANK REMOVAL ❑ OTHER <br /> 0 DATE DISCHARGE BEGAN METHOD USED TO STOP OISCIAARGE(CHECK ALL THAT APPLY) <br /> u a o r ❑ UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK ® CLOSE TANK <br /> HAS OLSCHARGE BEEN STOPPED? ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> o ❑j YES ❑ NO FYES,DATE 0 wj 7 Ml 1 aj 2 01 9 ,10 r Cl OTHER <br /> ED w SCURCE OF DISCHARGE CAUSE(S) <br /> TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPIV <br /> `TXS ❑ PIPINGLEAK ❑ OTHER ❑ CORROSION ® UNKNOWN ❑ OTHER <br /> LU a CHECK ONE ONLY <br /> �� ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY 1F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> f OHECK ONE ONLY <br /> ¢=Z €II <br /> ❑ NO ACTION TAKEN ❑ PRELgdINARYSITEASSESSMENTWORKPLANSUBMITTED ❑ POLLUTIONCHARACTERIZAT]ON <br /> Uy ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING N PROGRESS <br /> 0 REMEDIATION PLAN Q CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTIONS) ❑ EXCAVATE 3 DISPOSE(ED) REMOVE FREE PRODUCT <br /> �e.a�ranoerxA ❑ (FP) ❑ ENHANCED 810 DEGRADATION(tT) ( <br /> ow 4 ❑ CAP SITE(CD) 0 EXCAVATE 3 TREAT(ETI ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> LU <br /> a ❑ CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) <br /> m ❑ ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS} -Z <br /> ❑ VACUUM EXTRACT(VE) Q OTHER(O-n Com lete remediation planning in progress C <br /> Z <br /> W See attached report for hazardous waste manifest for rinsate, certificate of <br /> odisposal for tank metal, and laboratory Certificate of Analysis. <br /> HSCos(11/" <br />