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FORD CONST. aimFax:209— Sep 2 9:23 P.02 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY t]S QNI Y "' <br /> REPORT BEENFILEDz )H"cFi fk6 Fm' - THls F}IAY DIS�RIBI) 0035 FOR1aWTIbN OO6RDINGTOTFfE <br /> 0 <br /> YES ® NO Q YES ��NO � TE � jN ' <br /> 'S1'3i'9JT1�WNCtiTlEllJi_TRUCiIONS�r1EETONYNS P}wcOF?HSrCFtt+� <br /> REPO RT DATE CASs/ ' �� : s <br /> F , <br /> NAMEOF INOIVIDUALFIUNG REPORT PHONE SIGMA <br /> BOB' JONES.:_ . . d,('209).333.;-11-16 :. <br /> .• O REPRESENTING REGIONAL BOARD -COMPANY OR AGENCY NAME.' .. - <br /> . .® OVINER/OPcRATOR Q . <br /> g ❑ LOCALAGENCY ❑ OTHER WOODBRIDGE PARTNERS <br /> c AOJfIESS. - <br /> 639 E. LOCKEFORD STREET LODI CA 9524 <br /> 3YFCt7 CITY STAT{ ZIP <br /> w NAME CONTAATPERSON PHO E <br /> WOODERIDGE PARTNERS ©UNKNOWN BOB JONES (2 ,9) 333 -111.6 <br /> 'L <br /> a ADOR=SS <br /> 639 E. LOCKEFORD gTEET LODI C 95240 <br /> CIT'/ sTaTt: e <br /> FACILITY NAME(IF APPLICABLE) PERATOR PITO'E <br /> O <br /> z VICTOR MEATS 10 ) <br /> � ADDRESS LODI SAN JO 9UIN 95240 <br /> g <br /> 18846 N. S';4jp HwY 99 <br /> Cf7Y courrry <br /> wzie <br /> y CROSS STREET <br /> CLARKSDALE <br /> C7 LOCM,AGENCY AGENCY NAME CONTACT PERSON PHOE <br /> x� SAN JOAQUIN PURLTC HEALTH SERVICES VIDAL PEDRAZA (2 9) 468-0333 <br /> O REGIONAL,BOARD PHO c <br /> H (t) NAME UANTIFY (GALLONS) <br /> �0 4IF.ISBI' ® UNXNDWN <br /> 4 J <br /> �7 <br /> y a UNKNOWN <br /> i DATEOISCOYERED HOW DISCOVERED INVENTORYCONTROL O SUBSURFACE MONTNRING ❑ NUISANCE CONDITIONS <br /> 0 8 j. 1 j 7 0 0 0 r ❑ TANK TEST ® TANK REMOVAL ❑ OTHER <br /> a <br /> DAT---DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> m <br /> g <br /> of o r ®- UNKNOWN Q R6MOVECONTENTS CLOSE TANK 3 REMOVE REPAIR PIPiNM <br /> HAS DI_SGHARGE BEEN STOPPED? *SEE COMMENTS ❑REPAIR TANK 0 CLOSE TANK A FILL IN PLACE CHANGE PROCEDURE <br /> S2 ® YES E] NO IF YES,DATE M ►� o r Y ❑REPLACE TANK E:] OTHER <br /> SOURCE OF DISCHARGE CAUS'c(S} <br /> Q TANK LEAK ® UNKNOWN O CYER:TiLL RUMAEIFAILURE SP <br /> 0 ❑ PIPLNG LEAK O OTHER CORROSION UNKNOWN <br /> W cw CHfGKONE ONLY <br /> 6 ® UNDETERMINED ❑ SOIL ONLY ❑ QROUNDWATER ❑ DRINKING WATER'.'(CHECK ONLY IF WATER WELLS kAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> ® NO ACTION TAKEN ❑ PRaLIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED © POLLUnONcHAAACTERIZATION <br /> W <br /> 4 ❑ L.EAK BEINO CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY Q POST CLEANUP MQNrrO,IING IN PROGRESS <br /> N <br /> ❑ REM:DIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPR3ATE ACTtON(S) Ej EXCAVATt L DISPOSE(EO) ❑ REMOVE FREE PRODUCT(FP) ❑ EN ED BSO DEGRADAT1O,F(I i <br /> f Q ❑ CAP SFM(CO) ❑, EXCAVATE a TREAT(E) ❑ PUMP E TREAT GROUNDWATER(GT)Q REPLA¢F SUPPLY(RS) <br /> ul <br /> Q CONTAINMENT BARRIER(GS) ❑ NO ACTION R.DUTAED(NA) ❑'TREATMENT AT k00KLIP(KN ❑ VENTI IL(VS) <br /> VACUUM EXTRACT(VS-) ® OTHERCOT)••,ASSESS SITE TO EVALUATE APPROPRIArfE ACTION <br />'I * LAST KNOWN USE OF UNDERGROUND STORAGE TANK WAS- 1996- THE TANKS WERE <br /> EMPTIED AT THAT TIME- <br /> r K= Iia <br />