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INS JMONS
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<br />Leik,bein-'' 69. nfirm d -:Leak a� rmed., .w ,
<br />suspected,. at; .a: t,e, but, sr X
<br />fr
<br />lad, caw whether eme'r.e,nc response personnel and e 'i 6ient vase involved
<br />r'.Xali.n,sir Site Ass _smmnt Wo-knlanSuba'Xj.tteel arc t M
<br />.t any time, If so, a _lazaraaus Material. Incident Report should-be: filed
<br />err as ed of/submitted by .r.sporlsible party to deter, .: ,. whether s, caand
<br />with the State Office of Emergency Ser ' res (DES) at 20i endow ey Rodd, .
<br />watsr as been, or will be, impacted as ares sI.t. ct cleas-_Sacramertc,
<br />CA 95832 „:.,cries of the OES report formmay be obtalaied at
<br />Pr liminar Site Assessment UnderitiEa?* - implemental. _,a. wosrk,,:an.
<br />your local undex4r s id a to-rage -t<ank p e-rMitt ng agency-: > lud ca' e wi�et kaer
<br />Pol `auXl io.t Cha+-�racterizaon - responsible party is ria I ly
<br />tt?:r .O S rep=ort has t,....n filed as of th' , nate of this -pport:.' ®`
<br />defining the `extent of contam__>a t or -iii soil andg. , eater and a:�: zg
<br />i
<br />.v. _
<br />s-,
<br />mpaq s on.szr£aae and/or groan water. ,.
<br />aa�
<br />LXAL _.tea` ON1,y' ^ ` -
<br />Reis',6diation`,Plan - remediation p=ar submitted eka .._-: 10,1u, >evir
<br />c avoid d dapl; cme .,,otar :� xtion � xrsuar ; t ' ?ea'th -and Safety race ec`,ien
<br />ren'Iedi.ation' options. Proposal and implementation ,> a;.,,s ..o f z appr.6pricte
<br />C
<br />„� , 5, . a. government e pj.cspyee should sign: and cate4he fo.;YwS,, In Unto block...,
<br />2",115
<br />remediation: options .also submitted,
<br />Asignature here dfJP.,..... n Jt.".:. mean that the leak has beer. det6nsine:? %.-3 pose"a.
<br />'".� Clean`,= Underway - implementat,ion o relYECdl2itS.I.;X �.._„�"d",.
<br />Significant. threat to-i.u,t:ar_ naz th or ai'.ety, on thatnFxt.7.ftCatidii
<br />Fo 'ts Cilcanu Mon3.torinF'.,. in r.ogress ,Pe,riodic i'rouJ _,� �, u„ r �,st.asr.
<br />procedures have been fo.11owed if reclui yed
<br />monitoring"'at site as necessary', to verify and/or _.' !ate e=fep ive.ness
<br />-
<br />of remedial activities.' � -
<br />Ejf'iiRT h- BY ,',
<br />Case Close i -regional board an local agency _a_.;w. u;ta, no.
<br />Enter your name, telsI5bon1:3 number r, and'''C d.reHS; Indicate YdI<i Gli party v,.o`.'f:.
<br />,• further awG`i'k 1$ n2U°eSSa,ry. at the site,
<br />represent and -ovide ccs; aalany or, agency' name. .
<br />IMPORTANT: THE Ii(l,ilf3N PROVIDED ON THIS-FORM 75NFOR GcNLdA..
<br />' PESPONSIBLE. PARTY
<br />STATISTICAL PURPOSES fl LY AND 1S NOT TO BE CONSTRUED AS l..saL iTT.dC lL
<br />'Enter name,'te._epbor.._ numt>er, contact _nelson, and address 9f ;.he party
<br />OFFICIAL POSITION OF ,ANN VE:RIIMENTAL AGENCY
<br />` responsible fbr the leak, The xespnnsa�'"ie isax�y would not5fally be the- is fk
<br />outer_
<br />RDi9% ACTION f
<br />Indicate which action have been used to cleanup or r to __ sN the leak.
<br />SITE LC;CATIC;N � ` r
<br />Desoriptaens of options follow:
<br />,.
<br />Enter,.-reformation regarding the' tank, facility. At a minimum, yoga must
<br />s` s, Provide the facility name and Brill address,
<br />gap Sx 2 wnsta11 horizontal impermeable layer to a° '.-' c rainfall
<br />inMt rat;, on .
<br />IMPLi.'iuIN"ING AGENCIES
<br />Containment Barrie' - install vertical dike to moT.emIent of
<br />.. Ernter names of the ?ocal agency Yand i agJonal,:Wa e: 'Qta3l wtY Control Board
<br />contaminant.
<br />1n=robed, --. .p '.
<br />_.
<br />1sYGaEat.eia2"zd Di YiSe - remove contaminated soils and <°!.; ,Ws *3 in 'p r., ed
<br />„.
<br />.:
<br />site.
<br />. ...-
<br />" ,i;,z, TANCES INVOLVED
<br />Excavate and Treat - remove contaminated soil and t., :t', t_ il,l=,. es spreading
<br />Enter the name and ga_antrity lost'of the hazardous substance involved. Room
<br />or land fari.ing).
<br />as provided for informal-ion-an two substancesif appropr.ate. If more then
<br />Remove Free Product ._ remove floa`„ing product from rabble a
<br />two substances;leaked,''izst the two ot'mast concern for cleanup.
<br />PurilLand :real Groundwater - generally employed to dissole
<br />contaminants.
<br />DISCOVERY/ARATEMEN'I �'
<br />Enhanced Riode€ radation - use of any available techn-1. : ,,; ua' romot,a"
<br />Provide .nfo_x ani r r4g%a; ding the discovery and abatement of the Leak,
<br />bacteria], decomposition of contaminants.
<br />' �.� "-.•�
<br />il.e I.aC P. sill ly - provide alternative 'Nater' supply i,', i':. 'fed miss.
<br />Pn p 2 l
<br />SOURCE/CAUSE` ;
<br />._..L ......._..__._
<br />Txaatme t at i?oakap install water treatment de,�sc_,s: oach..�iFrellirg or
<br />s.i,.cate sourueXr of _.ea `i heck Lox es' indicating ,caa e,of leak..
<br />other placeof use.
<br />Vacuum Extract,,- use pumps or blowers to draw raiz
<br />ASE TYPE _.
<br />Vent Sod ., - Dore holes in soil-to allow volatiliz t ,Obutaci .Tants,
<br />Indicate thease stype category for this leak.- check one ;box only, Cage
<br />s.a
<br />No Acbion Rtcr-aired - indolent is minor, requiring r.�� _- adia adorn.
<br />tyntype is ,i:a re on tl P Most .i.>7 -
<br />�:ve ze:,c,uroe a.ffeeSeci: Four example, if
<br />..-
<br />both soil axxc « r_ourd � `fez hove been affected, ease, type wi,Ll be "Ground";
<br />C4?MNTS ^ Use this space,to elaborate on any aspects of t . incidLnL.
<br />��
<br />Waiter", lndA-ate "Drinking Water" only if one or n�ire_murrir.,ipal. or
<br />domestic water wells have actually been affected. A ."Ground Water"
<br />SIGNATUR;,;,7 Sign the firm in the space provided.
<br />designatd-on r not imply thai=the affected waiter cannot be, or is not; '
<br />used -far'drir tg'water, butt only that, dater ,wells have not yet been
<br />DISTRIBUTION
<br />affeytsi. 1 understoodttaat case type maqchange,upon`-further
<br />i the form is completed by the tank owner or hls agent, 2r rstt :_^.e last -,any
<br />invesElgation,
<br />and forward the remai�aing copies intact to -yo ar lural r,amk c inning agency
<br />�
<br />fon dssrributSon.
<br />CURRENT STATUS � � r '
<br />1.-Orig3na_- Local Talk Permitting Agency�
<br />Indicate theCat.egorV`V3 L^h best,ctescribas fila current statusof tl'S Ca5„('...-
<br />2, Stale Water .Resources Central Board,. Uivi.sion. of Clea:, fat.e:?:'t" Gs-,_riilc',
<br />' Check one box only. The ;response should'be relative„. o thea-e✓rese, tvpa. b.f
<br />Under"ground Storage Tank Program, P,O..Box 944,212, aoiam.,Bla, UH 94-2.44-
<br />example, if case type is "Mound Water—%their "Current Status" should rafts
<br />7.12
<br />to the status of t :e''-grruan I water` invests at%on or c; aa_..lr: as opposed to
<br />3. Ra iot,al Water Qua zty Control Bard
<br />that of sail. DescX iptiions of option's follower,
<br />4. Local Health Officer and Couslt.y Board of Supervisor,; ;;. ,,:weir dje5ig..ee to
<br />Propositi:un 65 notifications,
<br />: No Action Takon No action has been takep:by responsible,part:y beyond
<br />, trrner,/r,suo;sihle party,`
<br />in al Ceport
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