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UAR/PROP 65_PRE 2019
EnvironmentalHealth
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PR0231561
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UAR/PROP 65_PRE 2019
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Last modified
11/18/2020 4:08:57 PM
Creation date
11/4/2018 4:22:39 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
UAR/PROP 65
FileName_PostFix
PRE 2019
RECORD_ID
PR0231561
PE
2381
FACILITY_ID
FA0000104
FACILITY_NAME
QUICK N SAVE*
STREET_NUMBER
7200
Direction
S
STREET_NAME
EL DORADO
STREET_TYPE
ST
City
FRENCH CAMP
Zip
95231
APN
19316002
CURRENT_STATUS
02
SITE_LOCATION
7200 S EL DORADO ST
P_LOCATION
99
P_DISTRICT
001
QC Status
Approved
Scanner
SJGOV\rtan
Supplemental fields
FilePath
\MIGRATIONS\E\EL DORADO\7200\PR0231561\UAR_PROP 65.PDF
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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 SERVICESFORLOCAL-AGENCYUSE.ONLY <br /> ❑ YES NO REPORT BEEN FILED 7 ❑ VES ❑ NO I HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TOTHE . <br /> DISTRIBUTION SHOWN IXJ THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM. <br /> REPORT DATEQ CASEi <br /> M Du S 9 A q SIGNED DATE <br /> NAME OF INDIVIDUAL FH.ING REPORT PHONE SIGNATU <br /> n a 3448 <br /> w REPRESENTING ❑ OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> s <br /> LOCAL AGENCY OTHER�E►7 ❑ N (V4 WiAe4A OKI <br /> a ADDRESS <br /> 3 t,� � V°'1✓E Stnc l_tmj CA 952-0`_ <br /> mR&er cm STAn zlv <br /> w NAME <br /> ¢a ACONTACT PERSON PHONE <br /> � ^zq 6 <br /> y v E:] UNKNOWN iDDRESS, MobESm <br /> yO� tk {y Q `( <br /> � <br /> CRY STATC C•� p <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> c,�_ GIkven— <br /> Z-e,b <br /> a ADDRESS <br /> J <br /> Z� 5, EL_ C KfhQO Rag-tj r'1P 51tAi 3c q U 9523 <br /> F arRcn CITY couNry <br /> y CROSS STREET <br /> LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> �.0. �0 IROS 3�t*' <br /> a: REGIONALBOARD C,JZY�Si'P�L u��AJ PHON <br /> J5 7I Cfjoettf�j -L:0>06 (916)255 .3131 <br /> w (9 NAME OUANIT(TVL ST(GALLONS) <br /> �Lmk UNKNOWN <br /> �O <br /> � m _ <br /> 64,1`{ <br /> UNKNOWN <br /> i DATE DISCOVERED HOW DISCOVERED a INVENTORY CONTROL O SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> M V u p Y ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> a DATE DISCHARGE BEMMETHOD USED TO STO D�HARQE(CHECK ALL THAT APPLY) <br /> w <br /> u o r � UNKNOWN ❑REMOVE CONTENTS CLOSE TANK A REMOVE ❑REPAIR PIPING 9 <br /> HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK ❑CLOSE TANK A FILL IN PLACE ❑CHANGE PROCEDURE <br /> Q �{ YES ❑ NO IF YES.DATE <br /> /.1 1 R Y Y ❑REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGE CAUSES) <br /> ❑ TANK LEAK �i UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER )" <br /> ww CHECK ONE ONLY <br /> UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w� ❑ NO ACTION TAKEN ❑...JJJ PRELIMINARYSITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> jy ❑ LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTIONS) Eln EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) O ENHANCED BIODEGRADATION(I <br /> IM£APPROPRIATE <br /> k <br /> 4 CAP SITECD <br /> F3 ❑ ( ) ❑ EXCAVATE TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(OT)❑ REPLACE SUPPLY IRS) <br /> <'o <br /> ❑ CONTAINMENT BARRIER IDS) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENTSOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> a YY�lv �C11+— /�2ca.0 tA/i n,(� �b4/U6 <br /> iY1I,GaV',7Cx 0 '-`• <br /> NAC OS IB'oq <br />
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