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UAR/PROP 65
Environmental Health - Public
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PR0231761
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UAR/PROP 65
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Last modified
7/6/2020 4:43:54 PM
Creation date
11/7/2018 9:20:07 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
UAR/PROP 65
RECORD_ID
PR0231761
PE
2361
FACILITY_ID
FA0002347
FACILITY_NAME
ERNIES GENERAL STORE
STREET_NUMBER
4407
Direction
E
STREET_NAME
WATERLOO
STREET_TYPE
RD
City
STOCKTON
Zip
95215
APN
08710059
CURRENT_STATUS
01
SITE_LOCATION
4407 E WATERLOO RD
P_LOCATION
99
P_DISTRICT
002
QC Status
Approved
Scanner
SJGOV\rtan
Supplemental fields
FilePath
\MIGRATIONS\W\WATERLOO\4407\PR0231761\UAR PROP 65.PDF
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EHD - Public
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i -vs <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY AS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENCYUSE ONLY <br /> REPORT BEEN FILED 7 I HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMAT CN ACCORDING TO THE <br /> ❑ VES NO ❑ VES 0 <br /> DISTRIBUTION SHOWN ON THE INSTRUC�EETO ACK PAGE OFTHI�M <br /> REPORT DATE CASEk <br /> M M O 3r SIGNED. DATE. <br /> AME OF INDIVIDUAL FILING REPO PHONE SIGNATURE <br /> > 'not,o ti (Z a? 1 Yb8 D33 y <br /> w REPflESENTIG ❑ OWNEHIOPERATOR ❑ flEGK)NAL BOARD COMPANY OR AGENCY NAME (] /� <br /> S LOCAL AGENCY ❑ OTHER a h o 9 L/ A l//� -T Ws-£-140 <br /> a <br /> ADD <br /> 1RE <br /> LSS ,{/- Q .�e <br /> Ll S / f'/73TREEf 4 I Cm J��-JC 1}-Z> l STATE rot 21—P <br /> w NAME ` CONTACT PERSON //11 LI PH9O(N�E q c� <br /> iQ f G✓lt lq Seo/e ❑ UNKNOWN £✓11'IC (J Iia nITCCC"II <br /> Nn AlD1DR1E1S/S� 1 / LSI _/ (/y� / ZS <br /> 2 "T L4 V STREET W Q /V (Do V1 Lm G / �^ STATE (ef IP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ,I ervfl tl S��ry, 611anne ct 'klI <br /> U ADDRESS 3 <br /> cl <br /> 4L[D7 Ua o <br /> w STREET cm 4 C '7 couNry C' IP L <br /> H <br /> CROSS STREET <br /> ❑ LOCAL AGE CY AGENCY NAME CONTACT PERSON PHONE <br /> ~w C 7 4-H-J✓ a , <br /> w w REGIONAL BOARD PHONE <br /> V Q o (%o) 2-6 31 U <br /> w (�) NAME QUANTITY LOST(GALLONS) <br /> w UNKNOWN <br /> Z <br /> m° R) <br /> D UNKNOWN <br /> i <br /> 2 DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> MI M o Y 2 T ❑ TANK TEST ❑ TANK REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> 0 REMOVE CLOSE TANK&RE <br /> PIPING <br /> HAS DISCHARGE BEEN STOPPED 7 r NKNOWN ❑REPAIR TAANNKTENTS ❑❑CLOSE TANK&FILM NVPLACE ❑CHANIGE PROCEDURE <br /> o ES ❑ NO IF VES,DATEM u r r ❑REPLACE TANK ❑OTHER <br /> ¢ ❑ <br /> = SOURCE OF DISCHARGE <br /> LEAK ❑ UNKNOWN CAUSE(S) <br /> OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> 0 O ING LEAK ❑ OTHER ❑ CORROSIONS UNKNOWN E] OTHER <br /> N wn CHECK ON t•` <br /> 0 UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) w <br /> CHECKO NLY <br /> w Z NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION (� <br /> ¢� ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O m ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> IaE anc+Rll PEl�,B) <br /> ¢z ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) E::] PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY IRS) <br /> w <br /> wV F--] CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ¢ <br /> ¢ OTHER O <br /> r❑ VACUUM EXTRACT[VE) ❑ ( T) <br /> �7t�M �`rlc f'`i�- ��� � Con/�rI7'�2� �i p✓/ <br /> HSG Z(mo) <br />
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