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UAR/PROP 65
Environmental Health - Public
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PR0523164
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UAR/PROP 65
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Last modified
7/6/2020 4:43:41 PM
Creation date
11/7/2018 9:57:39 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
UAR/PROP 65
RECORD_ID
PR0523164
PE
2381
FACILITY_ID
FA0015636
FACILITY_NAME
STOCKTON REDEVELOPMENT AGENCY
STREET_NUMBER
666
Direction
W
STREET_NAME
WEBER
STREET_TYPE
AVE
City
STOCKTON
Zip
95203
APN
13737002
CURRENT_STATUS
02
SITE_LOCATION
666 W WEBER AVE
P_LOCATION
01
P_DISTRICT
001
QC Status
Approved
Scanner
SJGOV\rtan
Supplemental fields
FilePath
\MIGRATIONS\W\WEBER\666\PR0523164\UAR_ PROP 65.PDF
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EHD - Public
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• � ,� # n y -IJYE" <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />FOR LOCAL AGENCY USE ONLY. <br />�/ VES REPORT BEEN FILED? NO <br />❑ VES [pr'NO ❑❑ <br />I HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br />DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM. <br />REPORT DATE <br />CASE;1 <br />®M I <br />SIGNED DATE <br />• y r Y <br />NAME OF INDIVIDUAL FILING REPORT <br />PHONE <br />SIGNATURE <br />m <br />O k, <br />V1 )"/� 1 pc/ <br />U17Lcl, <br />REPRESENTING ❑ OWNERIOPERATOR ❑ REGIONALBOARD I <br />COMPANY OR AGENCY NAME <br />¢eLLOCALAGENCY <br />S <br />❑ OTHER <br />V <br />¢ <br />ADDRESS VA <br />1 le wt( Ave Lir �Yotk gfiaC G- <br />le <br />REE.E ZI <br />NAME OU . \✓v ^ , <br />CONTACT PERSON <br />PHO/NEE <br />z¢ <br />UNKNOWN <br />(,;or <br />H a <br />ADDRESS{��Y� j�['�/� <br />S*C H <br />STPETT\ • � STATE ZIP <br />FACILITY NAME (IF APPLICABLE) <br />FACILITY <br />OPERATOR PHONE <br />o <br />fDvyw pooj vvv\4skG-*Q�Dls3`1 <br />( ) <br />oADDRESS <br />S <br />(1 - V -V^ p j/� y\��VL/ {(.�\�[Jy I �>n5a� n QS�v 3 <br />W ��fREE( l� - <br />V�j7� • C" Ary CO ZIP <br />w <br />CROSSSTREET D <br />to C <br />c71NCV <br />•� n_ ,_ AGENCY NAME <br />CONTPERSON� <br />PHONE -;t4uX <br />F: w <br />\tj�t6 <br />qmjwOVA <br />wti <br />Lymftht <br />w <br />REGIONAL BOA,RDa ;�Y^ <br />1/ <br />YA, <br />PHONE <br />V <br />y <br />(7) NAME QUANTITY LOST (GALLONS) <br />[E�UNKNOWN <br />J <br />...."n� vv <br />F <br />m i <br />(2) �n <br />y <br />UNKNOWN <br />i <br />DATE DISCOVEREDHOW <br />DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br />04 D1 OY I v <br />OVAL OTHER <br />❑ TANK TEST ©' TANK METHOD <br />aDATE <br />DISCHARGE BEGAN <br />USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br />©'REMOVE 'REMOVE CONTENTS❑2OSE TANK B REMOVE ❑REPAIR PIPING <br />w <br />M M 0 D Y Y <br />❑ REPAIR TANK ❑ CLOSE TANK b FILL IN PLACE ❑ CHANGE PROCEDURE <br />HAS DISCHARGE BEEN STOPPED 4 <br />o <br />I vv <br />VES ❑ NO IF YES, DATE 0 $MI <br />❑REPLACE TANK ❑OTHER <br />o o v <br />SOURCE OF DISCHARGE <br />CAUSE(S) <br />jQ❑ <br />TANK LEAK UNKNOWN <br />❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br />wo <br />❑ PIPING LEAK ❑ OTHER <br />❑ CORROSION Ej?�UNKNDWN ❑ OTHER <br />ww <br />CHECKONEONLY <br />O <br />UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY <br />w <br />❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br />� w <br />❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br />O <br />❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) dCLEANUP UNDERWAY <br />CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE B DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) <br />00 <br />I�ewxrrnot+.usl <br />❑ CAP SITE (CD) ❑ EXCAVATE& TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />wr <br />w a <br />❑ CONTAINMENT BARRIER (CB) ❑ NO ACTION REQUIRED (NA) ❑ TREATMENT AT HOOKUP (HU) ❑ VENT SOIL (VS) <br />❑�VyAC,U�UM EXTRACT (VE) <br />❑ OTHER (OT)fi; <br />i <br />I� <br />\V`A W fir' fC.P //6'1 oyl � <br />� (v\ <br />w <br />of <br />U <br />
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