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SITE INFORMATION AND CORRESPONDENCE_CASE 2
EnvironmentalHealth
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SITE INFORMATION AND CORRESPONDENCE_CASE 2
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Last modified
2/10/2020 5:49:18 PM
Creation date
2/10/2020 4:23:27 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
3500 - Local Oversight Program
File Section
SITE INFORMATION AND CORRESPONDENCE
FileName_PostFix
CASE 2
RECORD_ID
PR0545336
PE
3528
FACILITY_ID
FA0003776
FACILITY_NAME
KWIK SERV LODI BW 113*
STREET_NUMBER
420
Direction
W
STREET_NAME
KETTLEMAN
STREET_TYPE
LN
City
LODI
Zip
95240
APN
06202042
CURRENT_STATUS
02
SITE_LOCATION
420 W KETTLEMAN LN
P_LOCATION
02
P_DISTRICT
004
QC Status
Approved
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SJGOV\sballwahn
Tags
EHD - Public
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SHELL OIL COMPANY CHAIN OF CUSTODY RECORD Dale: <br /> RETAIL ENVIRONMENTAL ENGINEERING WEST Sri al No.: +501 Nage of j <br /> Site Address: I Analysis Requittl LAB: t -. T <br /> sI <br /> WiC#: 7 _ ! . CHECK ONE(I)BOXnNLY CT/l)T TURN AROUND TIMI: <br /> Shcll Engineer: 1'h(me No. ` IC? Quarterly Monitoring 5461 24 hours ( I <br /> r t <br /> Site Investigation 1 1 5441 48 hours <br /> ._._ Faa N: � v I I <br /> Consultant Name& Address: _1 cl Soil f(x disposal 1 I 5442 13 days (Nurrurl) <br /> Water for disposal I I 5443 <br /> -' 11 r E=� ) X C._'. , ` )=� 1�' .. Other <br /> Consultant Contact: Phone No. 9 1 to ^ ' Air Sample-Sys O&M I 15452 <br /> r-- NOTE: Notify l_ah as <br /> lie ( .�C'J Paa M: c 15�,-3' r ¢�+ Water Sample-Sys O&M ( � 5453 <br /> Comments: _ $ ["j) 24 as passible un1 Other I.I 24/48 hrs.TAT--- <br /> v, x <br /> QC °o1J1, >4 <br /> Sampled By: per, per, eD `4 r SAMPLE <br /> Printed Name: rz (At�l� 't+ �+ IR o j DM�IRI ON IAL CONDITION/ <br /> - - --- - - - -— --- — COMMf:NTti <br /> Sample ID Date Soil Water Air <br /> Ncono.of S U•I' <br /> J <br /> 4 X 0 _... <br /> Xc . , � �_._ .. <br /> R li ed By (si nature) <br /> name:- Dater 13 y R iv (signature - Printed name,., Date:_ ;/gJ <br /> >,v Time O / � -- <br /> ,1 [1�LLl/` / U _ Timc: )fix <br /> Rclinguishcd Ry (signalurc :• Printed name: Uate:; y� Rec�yal(sigp�tiure): Irinted name: Dale: <br /> f - i `j l' ',C: <br /> Time <br /> :%�' <br /> Relinyui y (signature): Nrinted name; Dite:? - ceived(signature): Printed name: Date:3 P1192 <br /> e Ie P�1 Time/} y� /I►nn 4.v Tienc:CgC)C� <br /> TIIF.LABORATORY MIIST PROVIDF A('OPY OF nils IIAIN-OF-CUSTODY WIT!! INV(11('F.ANI)RI?SIII.TS I <br /> 1 a.t krvi.eon Date: 1011 SNI <br />
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