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SITE INFORMATION AND CORRESPONDENCE
Environmental Health - Public
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EHD Program Facility Records by Street Name
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KETTLEMAN
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3500 - Local Oversight Program
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PR0545328
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SITE INFORMATION AND CORRESPONDENCE
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Entry Properties
Last modified
2/11/2020 8:51:28 PM
Creation date
2/11/2020 11:00:49 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
3500 - Local Oversight Program
File Section
SITE INFORMATION AND CORRESPONDENCE
RECORD_ID
PR0545328
PE
3528
FACILITY_ID
FA0009569
FACILITY_NAME
Custom Design Manufacturing
STREET_NUMBER
248
Direction
E
STREET_NAME
KETTLEMAN
STREET_TYPE
Ln
City
Lodi
Zip
95240
APN
06206046
CURRENT_STATUS
02
SITE_LOCATION
248 E Kettleman Ln
P_LOCATION
02
P_DISTRICT
004
QC Status
Approved
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EHD - Public
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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)!CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br /> FORLOCAL AGENCY:flSE ONLY 1 <br /> ❑ YES REPORTBEEN FILED? -❑YES El NO !HERE6Y CERTIFY TKIIT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE JWCJ T>(AT E!{AVE" <br /> REPOR7ER7k[I5 1NFOfiMATION TO WCAL- FICIAIS'PUfiSI)ANT TO SEC [ON 25s847 OF <br /> REPORT DATE TE DSAFfY£ODE ¢f <br /> CASES <br /> 9DATE ...> <br /> i <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> REP RES ING r7OWNERlOPERATOq ❑ REGIONAL BOARD <br /> Cr\O�MPANYORAGENCYNAME ,A�D <br /> O LOCAL AGENCY VI' <br /> ❑ OTHER �JGAa G!Y[ 6614 <br /> Ir ADORE D, �U� l� i""" <br /> STPIEET <br /> C,Tr STATE ZIP <br /> Lu NAME CONTACTPERSON ') PHONE <br /> co Fn¢ --�/ �(� �d �, 1 i ❑ UNKNOWN <br /> �a r l� 6� h? 33�-65d6 <br /> a <br /> a ADDRESS ��' r7 I SJ i W d. ' I /l' �J� / ' <br /> ,r STREET cm STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> < ADDRESS <br /> W / STREE7 CITY ZIP <br /> y CROSSSTREET <br /> (7 LOCAL AGENCY AGENCY NAME CONTACT PERSON .h PHONE <br /> Lu <br /> it w REGIONAL BOARD r J /PHONE <br /> CL <br /> _ J <br /> rn (t) NAME QUANTITY LOST(GALLONS) <br /> L) UNKNOWN <br /> L) [ E <br /> a� <br /> 9) <br /> m_ <br /> E:l UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY OONTROL ❑ BSURFACE MONITORING ❑ ^NUISANCE CONDITIONS <br /> Lu <br /> Log p� Q El TANK TEST Q TANK REMOVAL t/ OTHER C <br /> M o o r v <br /> m DATE DISCHARGE BEGAN MD US D TO STOP DISCHARGE(CHECK ALL THA Y) <br /> w u M o 0 Y Y u "mom METHODREMOVE CONTENTS ❑ REPLACE TANK CLOS£TANK <br /> 4 HAS�DISCHBEEN STOPPED7 ❑ REPAIR TANK` ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> ❑ NO IF YES.DATE 3. �l o Tr `'�r ❑ OTHER <br /> wSOURCE OF DISCHARGE / CAUSE(S) <br /> ,u�/ I <br /> a TANK LEAK UNKNOWN OVERFILL 0 RUPTUREIFAILURE E:] SPILL <br /> 9+� ❑ PtPINGLEAK ❑ OTHER ❑ CORROSION UNKNOWN OTHER <br /> r' <br /> Lu W CHECK ONE ONLY ;- <br /> v,4 <br /> ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ON Y f. <br /> 2 NO ACTION TAKEN f7 PRELIM[NARY SITE ASSESSMENT WORKPLAN SUBMITTED'. ❑ POLLUTION CHARACTERIZATION <br /> w <br /> UH ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY)) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE a DISPOSE(ED) ❑ REMOVE=FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(IT) <br /> I faE'E e�cKcortcerxs� .V . <br /> Q ❑ CAP SITE(CD) ❑ EXCAVATE d TREAT(ET) - ❑ 'UMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> UG CONTAINMENT BARRIER JCB) NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) OTHER(OT) q 4*�,o <br /> 440 <br /> ._ - HSC f55I 11f8fl} <br />
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