UAR/PROP 65_PRE 2019 - Laserfiche WebLink

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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT- - EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES REPORT BEEN FILED 7 FOR LOCAL AGENCY USE ONLY ❑ YES �O ❑ YES NO 1 HEREBY CERTIFY THAT I. HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE ��``�� ` DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM. REPORT DATE CASE s O M -� M �) ; Y SIGNED DATE NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE n w f- REPRESENTINGOWNEFUOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME p❑ LOCAL AGENCY ❑ OTHER (— w f\ e V C ¢ ADDRESS D Cly 6,00`1 1 S�nn 1��tmC�� Cl\ -090'-i STREET Ctll' STATE ZIP w NAME jME }} r C_ Co- CONTACT PERSON PHONE z )e-v U'1 ❑UNKNOWN �i� IJ �� p ('li�j) �1�1_ l� ./� Qa w '��odvC{S ADDRESS IJ OK (f� LTD t San P Rca rn or) c 6 �c 5 F 3 -09N STREET CITY STATE ZIP FACILITY NAME (IF APPLICABLE)OPERATOR PHONE o ChevrDn S--+'vice Sha1{ IDn # a-57-45 C hev �cn troc�vct� cornfony (q7,5) 8�1-$GrlS ¢ of ADDRESS 3CUl Wes Kelemctr� Lclne- Oct�-San �ogt5(vlrl g5lLiD w STREET CITY CO ZIP USd,�Y ~ CROSS STREET Lee- kv e n ve z LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE w� S��Svatch co✓nay pR.;-LmD E}grlIa Knoll (2Cq 34 L4 w CD REGIONAL BOARD PHONE Cen4ral valley 1R-WOC6 � lL�bP- `ThaY� 013i,Y3 W U w (i) NAME QUANTITY LOST (GALLONS) unleaded Gasoline- Z J < UNKNOWN In Z (Z) ❑ UNKNOWN z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS w w F- (� MI l- MI rZ DI -t DI Y U r ❑ TANK TEST :F?4 TANK REMOVAL ❑ OTHER m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) a M M D D r y UNKNOWN ❑ REMOVE CONTENTS ,,CLOSE TANK & REMOVE E] REPAIR PIPING w o ❑ REPAIR TANK ❑ CLOSE TANK & FILL IN PLACE ❑ CHANGE PROCEDURE HAS DISCHARGE BEEN STOPPED 7 o YES ❑ NO IF YES, DATE OM 1901 li ot ❑ REPLACE TANK ❑ OTHER Y Y SOURCE OF DISCHARGE CAUSE(S) a❑ TANK TANK LEAK UNKNOWN F--]OVERFILL ❑ RUPTURE/FAILURE E:] N U ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ;�l UNKNOWN ❑ OTHER w w CL CHECK ONE ONLY U �- ❑ UNDETERMINED Z SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CHECK ONE ONLY z w ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION N ❑ LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS U ❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY J CHECK APPPe OPRRIIATE ACTION(S) EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) (SEEZ o O ❑ CAP SITE (CD ) ❑ EXCAVATE & TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) w a F--]CONTAINMENT BARRIER (CB) ❑ NO ACTION REQUIRED (NA) ❑ TREATMENT AT HOOKUP (HU) ❑ VENT SOIL (VS) ❑ VACUUM EXTRACT(VE) ❑ OTHER (OT) � II I��el)rn(rlatrY SSC GiSSPSSr'7Pr)� Per�}O�rLP0. �U G�C.i-1nQ v'Cd }Icer( �X}C�9� o Setif ccn�al"(►naitC�l per Ge-4ker-Rya^ CGniingency Werk elo>1 ciar�t^G If, r{F, � 0 11 n i V/ VINM41ra 1-Qrrtoval 0'F Source Moe rl-tl by eXCavcailt"ir\ *j e`�O'vl'P6n NSC OS (890)