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I N STRUCTIO ice
<br />EMERGENCY
<br />Z ak £lea Y& Confirmed'- Leak .suspected at site, but has not been confirmed,
<br />Cndacate whether emergency response personnel and equipment were involved
<br />FrP_am=nest Site Arrear }frnf' Wo k la?n Submitted - workDiao/propCsal
<br />' at any: time. :>b;. a 11aZardCttS 3ic:t,ermal __sC/n.i &'Z:t. :a; ti:t'i, S}.'dGu.t:d l.?k? fa:.led
<br />rL'Clidest.erl ^vtjsUbrnitted ly respo,x ,,.his par ,y to. detcr,,azna YrS;.,.ti2�"..i: ground
<br />Wltl"I the c.�t,a'vC; Of face Gs Et':jcrggency Services (OES) a'. 2800 Meradowview Road,-
<br />water ;its been, or will be, impacted as a result of the `:ela:ase.
<br />Sacramento, CA 95832. Copies of tt.e CES report form may be obtained at
<br />Pia ar. n<ary Site As_r... ;nen uander:aav- mp2e,r, uta zqn of warkp?_ar..
<br />yCitzr Igca;.... taY:derf-x";b'rjLi7:d storage tank permitting agE'Y: y°. indicate whether
<br />'3 :l l.l.ution CY:araut ex'12a'',o.n responsible party -.5 in the "'.,"YS.'gCe.SS of ;:.ai.l }'
<br />the CIES, ronoxt has been filed as of the °;gate of ,this repcart„
<br />defining the extent of contamination in sail .:ratµ g_cixrd water aril assessing
<br />asacts on surfaces and/or grouzd water,
<br />LOCAL ACEIdry ONLY
<br />k nedi"'At,.on _l..az rear .,._ation plan submitted eva!ua ing long ..erir.
<br />To avoid d p'icatre notification pursuant to Health and Sa�fety code Section
<br />remediation elstions, Proposal and °n l,t ezat lon .c?acdu.e --o-,pprgpr a e"
<br />251853.5. a government employee should sign and date the So_-m in thi's black,
<br />remediation options also sttbErdtted.
<br />A signature here climes not mean that the Peak has been determined to pose"' a
<br />tationso
<br />CLera"cxi > i;:Yder�av� - i plectke?Ytation of renediaticn,plan.
<br />-imp
<br />significant t? teat to human health, or safety, only that notification
<br />Fbst MLeunu lions an periodic ground water or oa er
<br />procedures have been followed if reclu1r:yd.
<br />moxaitgxzr.g atSite, as necessary, toec-ify and/or evaluate effectiveness
<br />of remedial activities,
<br />LE_FORTED ?3Y
<br />Case Closed - regional board and Loci: agency in concurrence "hat no
<br />Enter you name, telephone niunber, and addressInd cite which party you
<br />further work is necessary at i he site.
<br />epxesent and.prc�ide company Cr agency nam..,
<br />0
<br />IMPORTANT: THE MOMMATION PROVIDED ON THIS FORM IS INTENDED FOR' GENERAL
<br />, ESPONSTBLE PARTY
<br />STATISTICAL Pi3EPOSES ONLY AND ?S' 240-T TO BE CONSTRUES AS REPR SENTINGTM"
<br />Enter name, telepli6ne nu lcet, contact person, and address of the party
<br />OFFICIAL POSITION OF AIT' GOVERIMNIAL AGENCY
<br />responsible for ",,ths, leal,. The responsible party would normally be the tank
<br />ea�xner.'
<br />Rl;MMAL ACTION
<br />Indicate wbich action have been used to cleanup or remediate the leak.
<br />SITE LOCATION
<br />Descriptions of captions follow:
<br />Enter information regarding the tank facility. At a minimuM;' you ,most
<br />provide the facility name and ``call address.
<br />Cao Site - install horizontal stitpaz,skeeala layer to reduce rainfall
<br />infiltration,
<br />TMPLEMFNTTNG AGF'NCI S
<br />Co .ta.im. }lent Barri, r -. install ver';ica_ dike to block horizontal movement of
<br />Enter names of the .local agency and Regional_ va.<: Qua, -. tj Control ."tri ul'L«
<br />involved. _
<br />Excavate azxc: iJ%S osA exagt"e contaminated soil and dispose in approved
<br />SUBSTARC}C
<br />.Y.i..^ ar? Y"eai, "' .;: t;iiiE7ve son' ami;iated soil and l:_i:at 'incI?L_des Fpreakl
<br />Enter the name and quantity hist of the hazardous szistaTacc'"s,tavaly d. Room
<br />or lanai farmiikg).
<br />is provided for information on two substances if appropriate,, if snore than
<br />Ramo e Free Product remove floating product from water table.
<br />two substances leaked, list tho two of mo st concern for -cleanup,
<br />1L.,., ..Y+d treat sr CllXd .2 FP gene -rally employed to t.emov' dissolved
<br />contaminants
<br />DISCOVERY/ABATEMENT
<br />i.aiYa�. ,ad Biode adaticxa - use bi' any avai l at ..., t .wa"k>xoly v t,3 F;a c m ;.<
<br />Provide _nforYS'.ti.an .regarding the discovery and abatement of the local':,
<br />bacteri..:al decomposition of co.,t<a.,:.inants,
<br />due r a a3 p:ovide alternative ative water supply to affected parties,
<br />.
<br />SOUPCE/CAUSE,
<br />ea_"Ment at. .Bc.okur, _ anst,all water t>ca"lent device., at each dwelling or
<br />ndicate sourcels) of leek. Check box(es) indicating arise of leak
<br />o a_ Place of use,
<br />' a uum E�:tct use pumps or blowers to draw air through soil.,
<br />ASE TYPE,
<br />x.t .>ea - bore holes in soil to allow volatz' � zatJ on of contam Wnar';s.
<br />Lrldicate the case 3}'"i;E, category ,'iG:.' trli.S leak. i)kk'r'Cl; one bait only. i',2'ae
<br />i1aCf t, tion ire wire'.: - incident, is mrinor, re�.:y4i,-ring no l:e4meCdial ac lon...
<br />type is Lased on the most senjsitive resource affected. 'For example, if
<br />both soil and ground water have been affected, case type will. be "Ground
<br />CC1.l�k,NTS Use this space to elaborate on any aspects of the incident,
<br />k
<br />Water". Indicate "Drinking Water" only if one or more mu.sc. al or
<br />domestic water wells have actually been affected. A "G'round 'nater°'
<br />SIGNATURE- Sign I e form'in the space provided,
<br />designation clues not mplly that L affected water cannot be, or is not,,
<br />used for driiUking crater, but only that water wells, have not yet been
<br />Pt-RTP{1T.t N
<br />affected. It is understood that case type may change upon further
<br />"f the Tori ie c pieced ay the tank owner or Iris agent, retain e 1�"s copy
<br />investigation.
<br />eiad forward .:: the remaining :cop;as intact, ::to your ' aca'? ,t,a :k. permitting agency
<br />for d i stri-lutJon,
<br />CIMENT a 3Tl'S
<br />1- O rg .saw Local l Tank ear;? ttinvg Agency
<br />Indicate the category wh"Ich best describes' the. current status of the ca,,e.
<br />"
<br />2, State Wi er Resources Control. Board, Division of Cilean Water Pr'og saris
<br />Check one boy only. : The resronse should be relative to the case type. Fol,
<br />Underero,und Storage Tank , Box 944212, S ,, anile ,ito; . 94244 -
<br />. xM. ,,e
<br />example, if Oise' LyPe i,`Grouufd aLe � "Cur,
<br />then _ex Statue" hu.,l irefor
<br />2120
<br />to i�h0' „ica3tus:br the ground water- investlgwtJon or clean p, as , opposed so
<br />3. Reg_ na"y. Water Qua' i ty Coat;rai Board
<br />that of so43. U cosi tions -o. options follow:
<br />'f. Local lir.-.alta Officer and C.cunt Board �i ul a,._..,, cr t,i n_e
<br />re-,siVe
<br />l`4fl Act on l` K Z; ", No act ..n has £?coir oaken 9JY".. ., .. 3?"1.>7.b l.G party 19ey,,,,,,.F
<br />_ :?" ,"'P �,. 3.,i_ Do —tyj
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