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UAR/PROP 65_PRE 2019
EnvironmentalHealth
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2300 - Underground Storage Tank Program
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PR0501739
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UAR/PROP 65_PRE 2019
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Entry Properties
Last modified
7/6/2020 4:44:19 PM
Creation date
11/4/2018 3:53:40 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
UAR/PROP 65
FileName_PostFix
PRE 2019
RECORD_ID
PR0501739
PE
2381
FACILITY_ID
FA0005206
FACILITY_NAME
GEORGES SERVICE
STREET_NUMBER
1600
Direction
W
STREET_NAME
DURHAM FERRY
STREET_TYPE
RD
City
TRACY
Zip
95376
APN
25510004
CURRENT_STATUS
02
SITE_LOCATION
1600 W DURHAM FERRY RD
P_LOCATION
99
P_DISTRICT
005
QC Status
Approved
Scanner
SJGOV\rtan
Supplemental fields
FilePath
\MIGRATIONS\D\DURHAM FERRY\1600\PR0501739\UAR_PROP 65.PDF
Tags
EHD - Public
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' 3 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES fOR LOCAL AGENCY USE ONLY. <br /> REPORTBEENFLEDT HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> ❑VES NO ❑YES ❑ NO REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25150.7 OF <br /> THE HEALTH AND SAFTY CODE. t U <br /> RAEPORTDATE�T 9 rt CASES 1)p[��.,,�/ <br /> 0 M 6 M V / it V Y ..SIG YEI 0 ` _._ DATE <br /> NAME OFINDIVIDUAL FLING REPORT /� PHW� SIGNATURE <br /> � �, �w- <br /> REPRESE NO ❑ OWNERIOPERATOR ❑ RE IONALBOARD COMPANY OR AGENCY NAME <br /> LOCALAGENCY ❑ OTHER vimau IN L-0• �N•IIG I' PrCHI JZf'� <br /> ADDRESS Nnr Or x sTa t#r7Dt-I/ <br /> 1 60/� /H [ Clry C HERE zP <br /> CONTACTPERSON PHO <br /> NNEQ <br /> NAME IVY❑ UNKNOWN ,Q� /(i /' / (2p/ <br /> ADDRESS /�Aw nnrd1 /� g5376 <br /> 600 /•6TnEE GtR�AM cm TRr'G HATE`, P <br /> FACILITY NAME IF APPLICABLE) / OPEMTOR r PHONE <br /> 57 <br /> 6R.V%G� Ok6�% 76R�F/Nj/SN/ (1A`V 835covim �/��l <br /> ADDRESS / q / /,y� O (� 2 ( � 9K_3 /6 <br /> l 6o o a 19011 l� l 'F,N`-cdvZIP <br /> CROSS STREET TYPE OF AREA ❑COMMERCIAL❑NWSTRNL ❑RURAL TYPE OF SINESS ❑ RETAIL FUEL STATION <br /> 3 E::]RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> g% LOCAL AGENCY AGENCY NAME ��n r/�� CONTACTPERSON PHONE <br /> s <br /> CO. <« tza91 �6Y-3 yid <br /> �j REGIONAL BOARD PHONE <br /> �� G ✓ RW t9/ 3�/shoo <br /> NAME WINTRY LOST(GAL <br /> LONSL <br /> u/NxNOWN <br /> 3 ❑ UNKNOWN <br /> t DAA�(TE DISCOVERED /} HOWDWCOVERED ❑ RYCONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCECONDR-ONS <br /> V M M OD I D lv O r ❑ TANKTEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> WM M D D Y Y <br /> HAS DISCHARGE BEEN STOPPED 7 ❑ REPAIRTANK ❑ REPAIRPPNG ❑ CHANGE PROCEDURE <br /> p 1 ❑ VES ❑ NO FYES,DATE M M D D r Y ❑ OTHER <br /> yk SOURCE OF DISCHARGE TMIKS ONLYICAPACITY MATERIAL CAUSEf3) <br /> ❑ TANKLEAK UWNOWN GAL ❑ FIBERG S ❑ OVERFILLREIFALUfE <br /> ❑ PIPINGLEAK AGE LE YRS EL ❑ CORROSIONUNKNOWN <br /> ❑ OTHERUNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w w CHECK ONE ONLY <br /> �� ❑ UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONLY <br /> a SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) ) <br /> ❑ N10 ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVALA13LE TO PROCEED [:] EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTON(S)(SEE BACK FOR DETAILS) <br /> ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BO DEGRADATION(IT) <br /> w� PUMP A TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY IRS)�� ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATEATREAT an ❑ <br /> ❑ TREATMENT AT HOOKUP(I" ❑ NOACTIONREOUIRED(NA) ❑ OTHER(OT) <br /> �diL Saw /e reSu/ S ✓a (/e-Gc 6 a A ah+iN4 <br /> ,f �le ,, v.el SSD Y4 y� vL(-c r�e ✓a�,� °h-/ y S-Ja <br /> n {y °�„awl w: L� b� ►^ rtii ear d .ti� <br /> MD061LO) <br />
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