UAR/PROP 65 PRE 2019 - Laserfiche WebLink

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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINA ON SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY ❑ YES NO REPORT BEEN FILED 7 ❑ YES ❑ NO I HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM REPORT DATECASE i MI r r SIGNED DATE NAME OF INDIVIDUAL FILING REPORT PHONE SIGN RE co Dina Abate ( 209) 468-3468 REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME L) ® LOCAL AGENCY ❑ OTHER San Joaquin County Environmental Health ¢ ADDRESS 304 E. Weber AVE #3 Floor Stockton CA 95202 STREET CITY STATE ZIP w NAME CONTACTPERSON PHONE zThe Record ❑ UNKNOWN Jim Franco 209)943-8550 ¢ 00o< AD RESS U)D w ¢ 930 F_ Market ST STREET StnvktnjjTY U STATE 99202 zip FACILITY NAME(IF APPLICABLE) OPERATOR PHONE z 0 The Record ( ) ¢ ADDRESS U ° 530 E. Market 9520 Stockton S.J. p Lu STREET CITY COUNTY ZI a—i CROSS STREET LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE zco Lu / ) Uww ` — 13468 REGOABOAR PHONE J< < Central Valley Jim Barton (916 )255-3115 y (1) NAME QUANTITY LOST(GALLONS) WO <Lu > gasoline UNKNOWN m z (2) �- fn ❑ UNKNOWN Z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS M M DI DI YI r E] TANK TEST TANK REMOVAL E] OTHER m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) < ¢ UNKNOWN ❑REMOVE CONTENTS CLOSE TANK&REMOVE E]REPAIR PIPING w M M D D Y Y X HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE F—]CHANGE PROCEDURE U o ® YES ❑ NO IF YES,DATE Q1 1.1 1 D 14 DI 0 Yj 3 Y ❑REPLACE TANK ❑ OTHER SOURCE OF DISCHARGE CAUSE(S) j ❑ TANK LEAK F UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL ON v ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER w w CHECK ONE ONLY U F� UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CHECK ONE ONLY QNO ACTION TAKEN F7 PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION < ❑ LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) J (SEE BACK FOR DETAM) a z ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) 0 0 w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) cr ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) z Re.sbAs t 6 /e fArt w , I I b e cti rcc4e J 4t 0 I HSC 05(B50)