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UAR/PROP 65_PRE 2019
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PR0231502
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UAR/PROP 65_PRE 2019
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Entry Properties
Last modified
12/31/2020 10:52:19 AM
Creation date
11/5/2018 9:35:47 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
UAR/PROP 65
FileName_PostFix
PRE 2019
RECORD_ID
PR0231502
PE
2381
FACILITY_ID
FA0003919
FACILITY_NAME
VAN DE POL ENTERPRISES
STREET_NUMBER
5491
STREET_NAME
F
STREET_TYPE
ST
City
BANTA
Zip
95304
CURRENT_STATUS
02
SITE_LOCATION
5491 F ST
P_LOCATION
99
P_DISTRICT
005
QC Status
Approved
Scanner
SJGOV\rtan
Supplemental fields
FilePath
\MIGRATIONS\F\F\5491\PR0231502\UAR_PROP 65.PDF
Tags
EHD - Public
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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HASSTATE OFFKEOFEMERG SERV <br />REPORT BEEN FLED?rJ�C.._' <br />WNO ES <br />FOR LOCAL AGENCY USE ONLY <br />1NEREBY CERTIFY THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br />TO SECTION 25180.7 OF <br />YES <br />4REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT <br />THE HEALTH NOS Y ODE <br />REPORT DATE CASE/ <br />M D D1 7YIV <br />scNw TE <br />NAME OF INDIVIDUAL FLING R RT <br />PHONE <br />SIGNATURR E <br />S NG OWNERfOPERATOR O REGIONAL130ARID <br />COMPANY OR AG/ENNCYYNOSE <br />P <br />¢LOCAL <br />O <br />AGENCY OTHER <br />rADDRESS <br />cS4 <br />a <br />¢ <br />v <br />�O C /<y_ <br />Oi S REE CRY STATE P <br />LH <br />A/�� ,,� f�� �,� <br />CONTACTPERSON PHONE <br />c��9) Ci 3 ✓ J� /[l <br />¢ <br />�G 1 .�'/VWI..J�Y-�� " ❑ UNKNOWN <br />I I V(J V L/�-+ <br />ADDRESS�� / Sfi� �e�jCp, <br />15 srREEr clrY STATE v <br />FACILITY NAME (IF APPUCABLE) OPERATOR PHONE <br />` o S—, -7 <br />de <br />_rm <br />ADDRESS <br />Q ��JQ (i <br />STREET EiiC�J• UYitirr"" <br />cm <br />W <br />CROSS STREET <br />TYPE OF AREA O COMMERCIAL O INDUSTRIAL O RURAL <br />TYPE OF BUSINESS O RETAIL FUEL STATK)N <br />O RESIDENTIAL O OTHER <br />O FARM O OTHER <br />N3 <br />LOCALAGENCY AGENCY NAME <br />S <br />CONTACTPERSON <br />PHONE <br />REGIONAL BOARD <br />Q C,B <br />HONE <br />( <br />(1) NAME QUANTITY LOST (GALLONS) <br />UNKNOWN <br />O UNKNOWN <br />w <br />DATEDISCOVERED <br />(X�, (J'y <br />WDISCO RED O INVENTORY CONTROL SUBSURFACE MONITORING O NUISANCE CONDITIONS <br />B u �+ u D D o Lir r <br />TANK TEST F-1 TAW TAREMOVAL OTHER <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THATAPPLY) <br />w <br />v/ <br />u u D D Y Yl l""'"'OWN <br />0 REMOVECONTENTS REPLACETANK Q CLOSETANK <br />O REPAIRTANK REPAIRPPNG CHANGE PROCEDURE <br />HAS DISCHARGE BEEN TOPPED? <br />p <br />VES F VES, DATE M M D DI Y y <br />O OTHER <br />yu <br />SOURCE OF DISCHARGE <br />TANK LEAK �N<NOWN <br />TANKS ONLYCAPACITY MATERIAL <br />GAL. O FIBERGLASS <br />CAUSE(S) <br />O OVERFILL O RUPTUPEFALURE <br />PIPINGLEAK <br />AGE 15 YRS `STEEL <br />CORROSION UNKNOWN <br />O OTHER <br />O UNKNOWN O OTHER <br />O SPILL O OTHER <br />CHECK ONE NLY <br />ty} <br />UNDETERMINED O SOILONLY O GROUNDWATER O DRINKING WATER-(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />�D <br />CHECK ONE NLY <br />OFF COMPLETED OR UNNECESSARY) <br />K <br />ITE INVESTIGATION IN PROGRESS (DEFINING EXTENT OF PROBUM O CLEANUP IN PROGRESSO SIGNED (CLEANUP <br />am <br />O NO ACTION TAKEN O POST CLEANUP MONITORING IN PROGRESS O NO FUNDS AVAILABLE TO PROCEED O EVALUATING CLEANUP ALTERNATIVES <br />CHECK APPROPRIATE ACTION(S) (SEE BACK FOR DETAILS) <br />oO <br />CAP SITE (CD) O EXCAVATE & DISPOSE (ED) O REMOVE FREE PRODUCT (FP) O ENHA -FD BIO DEGRADATION (IT) <br />wt� <br />O CONTAINMENTBARRIER(CB) O EXCAVATESTREAT(ET) O PUMP& TREAT GROUNDWATER (GT) O REPLACE SUPPLY IRS) <br />O TREATMENT AT HOOKUP (HU) O NO ACTION REQUIRED INA) O OTHER(01) <br />o o00s r <br />N <br />WJOO <br />Ili <br />/ <br />'Vl.�.f/J•V �//HM"�^�' �`--� YVL(/L/W `^� �i"i>v �v/L% ��������I�/✓`�`i/�'✓�'a <br />
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