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SITE INFORMATION AND CORRESPONDENCE
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3500 - Local Oversight Program
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PR0544601
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SITE INFORMATION AND CORRESPONDENCE
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Entry Properties
Last modified
6/25/2019 5:07:47 PM
Creation date
6/25/2019 4:35:36 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
3500 - Local Oversight Program
File Section
SITE INFORMATION AND CORRESPONDENCE
RECORD_ID
PR0544601
PE
3528
FACILITY_ID
FA0002253
FACILITY_NAME
JACK FROST ICE SERVICE
STREET_NUMBER
36
Direction
N
STREET_NAME
D
STREET_TYPE
ST
City
STOCKTON
Zip
95205
APN
15318028
CURRENT_STATUS
02
SITE_LOCATION
36 N D ST
P_LOCATION
01
P_DISTRICT
001
QC Status
Approved
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EHD - Public
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FILE COPY <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br /> REPORT BEEN FILED 7 FOR LOCAL AGFNCY 115E.QNLY <br /> YES NO <br /> YES NO I HEfTEBY CERT)F1!THAT#_HAVE,DISTR16UTEDTHIS INFORMATION ACCOpDfNG To 1 NE <br /> REPORT DATE0S7I90TfcNSH0WNCNT'HE-IN57RUCTIONSHEET6NT]iE_BACKPAGE T}i1S,FOR�L <br /> CASE t <br /> ;?.-I d d Y r f ' 9- <br /> SIGNED., HATE. ; <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> r a O z— (20co Y�aB'3YYa <br /> REPRESENTING O►YNERIOPERATOR 0 REGIONAL BOARD COMPANY OR AGENCY NAME <br /> a iOCALAGENCY Q OTHER r <br /> R +► cl u „� <br /> s ADDRESS !cAk <br /> 30 4 14vREET G4 iSZv <br /> CITY _ <br /> NAME CONTACT PERSON STATE 21P <br /> co <br /> /� PHONE r _ii - <br /> z¢ / O ��C!-7Seh c ICC 0 UNKNOWN L <br /> 0 ADDR S rzSe 4716(1 Y_ <br /> (� 7 <br /> ui <br /> y � q i , <br /> r� 7 Svc/� v h <br /> d G4 <br /> STREET CkTY STATE <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> a ADDRESS <br /> w STREET -2-i <br /> CROSS STREET op <br /> z LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> w� STC' �� vlr�vh. �{ /, iv ['u�1 QZ— ( '1Sr6�-3�Y7 <br /> �M REGIONAL BOARD PHONE <br /> a¢ <br /> LU f1) NAME QUANTITY LOST(GALLONS) <br /> Z w Ia/1NKNOWN <br /> in O <br /> 2 1 <br /> y <br /> UNKNOWN <br /> z DATE{{DISCOVERED HOW DISCOVERED Q IN ENTORY CONTROL SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> w M1 I Zfll ol Y r ❑ TANK TEST TANK REMOVAL OTHER <br /> DATE DISCHAIRGEBEGAN METHOD USED TO STOP OtSCHA (CHECK ALL THAT APPLY) <br /> mIllUNKNOWN REMOVECONTENTS CLOSE TANKS REMOVE a REPAIR PIPING <br /> ? HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK 0 CLOSE TANK&FILL IN?LACE CHANGE PROCEDURE <br /> cn <br /> p YES.! NO 1F YES,DATE M d r Y REPLACE TANK OTHER <br /> Lu SOURCE OF DISCHARGE CAUSE(S) <br /> a TANK LEAK E51UNKNOWN OVERFILL RUPTUREIFAILURE SPILL- <br /> y vPIPING LEAK OTHER CORROSION UNKNOWN OTHER <br /> ycv CHECK ONE ONLY <br /> EX <br /> UNDETERMINED SOIL ONLY El GROUNDWATER DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> wfn NO ACTION TAKEN PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED �LI LITION CHARACTERIZATION <br /> s ' <br /> 0 LEAK BEING CONFIRMED Q PRELIMINARY SITE ASSESSMENT UNDERWAY POSTCLEANUP MONITORING IN PROGRESS <br /> fn <br /> V REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) <br /> (� EXCAVATE 4 DISPOSE(ED) .REMOVE FREE PRODUCT(FP) F7 ENHANCED 910 DEGRADATION(IT) <br /> J 9�[`J(FOR 11Ff,V^$I - .. <br /> CAP SITE(CD) Q EXCAVATE E TREAT(ET) PUMP A TREAT GROUNDWATER(GT)0 REPLACE SUPPLY(RS) <br /> d Z <br /> 00 <br /> LU a CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) Q TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> Q VACUUM EXTRACT(VE) 0 OTHER(07) <br /> z <br /> l►1 L!erA So Og.%, <br /> 2 /1.7 y� So%� s ..r /ts t c to,-L oho-kc7 (c c l 53k is <br /> 0 <br /> - <br /> M3C 05 W" <br />
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