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R-GENC ...
<br />A ayt' Y3 e ii '�' s
<br />„OTi..t rt.ae£l �" +.xealk suspec e<d is `t site, h
<br />: alt;.
<br />not a.E3cni or.t...�'a^a,bd,'.
<br />1T_<X1Cat.B. wl.et.l"?.,,i IFi6' viAA3'? .
<br />e rg ,refponsc a -Sonne!. and eTuip92eX t were iiivo ived
<br />i`2 e3.imin=. Y ire .' "JeS r� t- kd`ll k12 ^,YI .J ..,.., S. i, eC? ... �.
<br />%.,m, j)rQPCSc`3 `.
<br />sany Lune, i sa.' a rsa7ardous I5atc `ai Incident Report should be fsled
<br />requested'of/subaditted by respcnzible paaty to e x_
<br />.;ac cher g„rund
<br />With the State Office r,¢ me jency Servi.,es t0ESI? at 2800 Meadm-rview Road,
<br />water has bee -1, or will be impacted as a i, ult Qf
<br />releaSe_l
<br />Sacramento, 'L:A 95832, .,,Fi,�a as ..3a. .1'.2 i),.FS _ oz.t,. fJrHs may be Ul3tci.neLS. at ^'
<br />ic.;
<br />R_L�.7�RI2r�:a Sw.tL _isse `7 s<ii ;.XiUU..d3r4€'aV ="u';��.e, ..2t e::'.
<br />your local umdergkouud storel . an,,. ermi .ting 'agency."' indicate whether �
<br />Pollution C,. aractelriza"ISiOTI -responsible party As
<br />-ooes,5 op K �i
<br />,.a9 L.. 'Clr,=:, ..::upon 'f7aS been ....d:z .,. v:,:, .Zi ,*; �? <tC> of �olii6s^ r9p;`.l''C t,. .v=
<br />.,
<br />>:
<br />d8 �.x.nin�' the e7,tent CLYiltatnin�:�i,ri, _ :.-C�. ,..:c. ,a
<br />.._ x.:.A.i assessing
<br />s e -
<br />,r="
<br />.
<br />. .
<br />tiiCpaCtS JSt:.2Ce andlor g3Ci.va.
<br />ft AGENCY ONLv ,�
<br />ie47iPtiQZ;1a.
<br />RCICdiat P1
<br />._..._
<br />ie?:t _
<br />d Sid auplicate,..no<.i.. „.C3 ,., Q... .=::J: s.wa 1v L,'J tli.3ai;7 d e'fQtvw. C -a Section,.,,
<br />'.ze€'iea' ation cp,<:�Q?`;s. Proposal s.?2,"Y ?C'T <,x.,...-..,.�, ,,a.. r,,,..
<br />,. f,;,r app Prieto
<br />r'i'te
<br />25180.5, a, s,,-overrcnent .t,.„..,,. a ,.cC^,i.; d ...gn r'+.nd Cate the..,.: form in ....a.5 b: ock.:.
<br /><s'remediation options .also submitted,.
<br />signature, here does n -m ._. ar he leak hes beer, determined Lo ,pose a,-'-
<br />t,'ar; UnderW:v - impp menta Wer c remeda.i.on 7
<br />significant threat to bA ,.san .._ alth' or safety, cInly a
<br />flat ro iftoa ton
<br />roost CL nam 4donitoring in vxo.re,s c.di<, h= �>.,.
<br />t_i or other
<br />v;zvicetiures have beer fc....o.,ed, i res, -eti, ;,
<br />'r .,
<br />;. .,
<br />monitor Ia at site, as necessary, to v r.. y ind/o
<br />: �ec
<br />a.e ,., i a,_Aess'
<br />o. ..., v
<br />#-.
<br />of resiedT.al activities_ r
<br />.
<br />REPORTED BY
<br />Vase Closed -- ieg o'ial board and local agency, in c't,;...
<br />;�ercG that
<br />cer your :Name tslpp ml er, ant address: lndicat.e which >arty you
<br />further work is necessary at the site,
<br />IW--src'sent and provide cotcpamy or ae ency tzame.
<br />{
<br />IMPORTANT: THE T FGw�TION PROVIDED Gid THIS PORI, Aar :1Yv..,.,
<br />r I? FOR GENIL r?L
<br />Q.ESDONSIBLE PARTY
<br />4(yTATTSTICAL PURPOSES ONLY"AD IS NOT TO BE CONSTRUED AS
<br />_:F:SE ".NG HE <,
<br />Enter name, telephone number, contact person, and address of 'party
<br />O`the _ ICIAL POSITION OF ANY GOVERNtIENTAL AGENCY
<br />responsible for the Leal;'.. The responsible party `would normally be the t.ark
<br />C,)Y;TieZ::
<br />iiE:"E=."l.IAt ACTION
<br />indioate which action have been used to cleanup or zea-d',__e
<br />leak,
<br />SITE LOCATION
<br />Descriptions of options follow:
<br />Enter information regarding the tank facility. At a minimum, you must
<br />;uroviae the facility n Te "_:w a full` eddzess_Cal
<br />S1 to - install horizontal imp -,meal_ Lc layer r. to .r
<br />__ _. Air'
<br />... �.
<br />in iltration. ., -
<br />au';*��n,
<br />IMPLEMENTING AGENCIES �
<br />.,
<br />j,, ntai=nent carrier ;install veztica_ dice to b,oc-
<br />> zont"A?.-'rsdvwcert of
<br />nt,erna€nes of the local age Acv 'and ' ,,ional Wa er Quality Control Board
<br />cortardnant,
<br />3vo ved, .s.iQSe
<br />a;xcavate and R _. remove conta,".,-_natG''t'i. soil an
<br />.�f3 .,..1 t..6-i%i"C3iTf'C`
<br />site.
<br />��UBSTANKES INVOLVED
<br />Excavate and Teat remove contaminated ea soi an
<br />i..,...u.-_.. s ,"r`eadzz,±
<br />rater the name and duan , avo: ved. Room-
<br />�._,, ._ �,.0 ,:, ,,a.., nocar ,Qaxs substance _ e
<br />._. }
<br />c la-ard _<. , .
<br />is provided for informat,ion.rrtx two sas,, tazaces if appropriate, If more than
<br />emove Free Product; remove floating product
<br />tabis,,i
<br />two substances Leaked, list the :two of most concern for cleanup,
<br />t im,- and Treat, Groundwater - generally empoyed t. ..
<br />_ dissolved
<br />lai at Oti';RS IABA EP R:dTFrslsoncecd
<br />Biode ra6a, 1.01, use of. any e aS la ? r c i._�
<br />s* « .p a c=nt,a
<br />information i:eg:m„3,,.ing_:11C-; Gt ,, ., i;;re ,,;.Tri. abate_nerat of the leak, q..
<br />. �,
<br />bacterial decomposition of coot T:"."..1raA?t,5,
<br />Suun1, " provide alter natwve water sa vuE'd
<br />C
<br />Ii atmant at Hoo .:iD :- install..water .,rcat.4T9f_,Af:,
<br />each �dw e, 1,11ng or
<br />a } - a
<br />.7.cate SL%U?: i,e{5}Oi A.. <2,tC. Check ,..:;stca.,,ilCiicatwng GeiEz9e £Y,, leak,otherplace
<br />�..a e if use,
<br />y,ftir)
<br />_ "ut,.. uC :. - use pump i1.T`?.71..'JYii.rs LCt Edi aro c11 Y° .,
<br />,.$"lk soil'. ,, w
<br />ASE TYPE
<br />Vent Soil _ base cif}.tsps .in soil to alloy volatillzat..
<br />_ of
<br />Inchoate the case' -typ ." „ t,x=g , to _s Leak." 'Cheek carte box- only, Case �
<br />o fact ao� Rema_ . _.l cin ident is minor, ;:art _ : ia,g t.
<br /><-, :M a_ action,
<br />won.
<br />_.. o resource affecl,.ed. For e ample, if
<br />type is based` on Tse- mos, , u-. .,
<br />both soil and,grnutad ease- h-,Ve beer affected, case type will be "Grouri
<br />M -VENTS aise this space`to elaborate on anyns oews .,
<br />V _..c; dent,
<br />Water”. Indicate';`Eric zap ti ator'< c, IF if one or more municioal oW
<br />tQTsiestic water wells -have actually roan affected, d "Grrsund7ater"
<br />SICNATtii2E < Sign the iorm': TT the space provided,
<br />desiguation does not: iCAp31.y 'thac the affected water. cannot be, Qr is not,
<br />�
<br />used for drinking water, but only .'�;ha a water wells have rot yet been
<br />LiiSTRI.BUTION
<br />affected. It is understood that case type may change upon, further
<br />If the form is completed by the tank owner or his agent,
<br />...ot:ain the last copy
<br />.__Avest.igation. s: -'�-
<br />and forward -,the re!?3rin.iitg.,.., copies intact to. your tical., tan"<
<br />�,.i,..L'i.A??; E. ;.TS;-, agency
<br />for distrib Alai QTT
<br />R. I i STATUS1.{.,r
<br />yy
<br />..gial '� '„3C c'?... Tank CE?r}T.:. t,'t l.a-sg..?2Cy
<br />z:
<br />Indicate the category whJ c 1 best de; c ibes the current status' of the casq, ,
<br />2. State Water Resources CoritroI Board, Division of Cies -�
<br />.,a,.. r ?tcn airs,
<br />Check one box only. The resronsp ,:, o:ald be r`.
<br />relative to the Dasa type. Fob.
<br />Underground Storage ;`ink Program, P.O. Boz. 944212,
<br />”CA 9422144-
<br />r.2rft,-example,
<br />example,if case .type is , : round, Water', them "Current, Status" should refer:
<br />232ti
<br />to the status of the;g_olun eater i>sves::ga,tiorIi or cleanup, as opposed to
<br />3. 'Regional Water Quality Carat -Z, Board
<br />that of soil. Descriptions of s�pLic) .> follow: i
<br />h: Local Health Officer _�ua,'Couhty Board of S=.pa:c_.;wi._
<br />.,:" their"dm Ignse to
<br />receive Proposition 65
<br />Na Action msk..n No pet_ sA .Aa` T t k en by resp ib e rty beyond
<br />:tiro-xer%responsible pa= y.
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