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ti;39 T ri 01NS _ <br />in box `. :;led "E1 r2CENCY", indicate whether ew6r9ency response personnel <br />a° r.,,ui;,-;ent were nvulved at any tient-. IF so, a Hazardous 611aterial <br />Ir c.ii:ent report should 5d fi l t o °rvi 1 t€ the :; ;rtz Office. of Emergency <br />Services (DIS; at 28n 1, dowview ':r)ar, Sacrarrierito, CA 95832. CoOes.of <br />:S r:pori fora ;.iay he ob`a,,-wJ at your local underground tank <br />per r ttir , nc e l 1n" -,,.ate wh€:riser the OES report has been filed" as of <br />tt f a tc (J thi=_ r�or- <br />In splice iprovided, enter state tank ID number if known. State ID numbers <br />)dve, been assigned to all tanks that are on file with the State Yater <br />Resources Control Board.�Enter today's date in the box titled "Report Date". <br />Enter local and Regional Wat'er Quality Control Hoard case numbers if <br />i:nown. Enter thy: jS EPA facjlity ber if applicable. <br />2. f.3r3ORIE;b 3Y <br />..nter`your name, telephone r4imber. ;c address. indicate which party you <br />rt r e ser{ :nM pr?vidt, company or agency name. <br />3 'E3`d`a' PARTY <br />,.rtrr th name, telephone number, contact person, and address of the <br />Party responsible for the leak; or mark unknown.- For tank leaks, the <br />responsible party would normally be the tank owner. <br />Mr^ `t <br />t <br />tion'rey.rdi'ig the tarp facility and surrounding area. If a <br />Known Larik,or favility.is-not involved, enter general location of the <br />contamination site as best possible `i.e..,street, city, county, zip, <br />cross street, and type, of area. ' ? <br />IPAPLEh€ELATING rtGEN jt 5 <br />. Enter names of the local agency, Regional Board and/or Toxic Substances. <br />Control Division (TSCO) regional office involved and a contact person and <br />telephone number for each. <br />6. SUBSTANCES INVOLVED <br />Enter the CAS num6er(s) (if known)., name(s), and quantities lost of all <br />hazardous substances involved. Attach an extra sheet if €€=ora than two <br />Substances are involved. Be as specific as possible. <br />7. DISCOVERY/ABATEMENT <br />Provide information regarding the discovery and abatement of the <br />discharge. More than one box may be checked in the sections titled "Now <br />Discovered" and "Method Used To Stop Discharge" if appropriate. <br />il.. TZm _ <br />8. SO[JRCE/CAJSE <br />Indicate sources) of discharge_ Provide details on tank age; capacity <br />and -ma terial, if a tank is involved. Check box(es) indicating cause of <br />discharge: ''More than one box may be checked if appropriate. <br />9. RESOURCES AFFECTED/AT RISK <br />In section titled "RESOURCES A'FEC;'ED" indicate whether any of the <br />resources listed have been affected ("YES"), will not be affected <br />or may be affected ("`iIREATENED") by the release, Check "UNMOWN" if <br />unsure of the status of a resource. Specify any unlisted: resources which <br />are, or may be, involved under."OTHER". The same instructions apply to <br />the section titled "WATER SUPPLIES AFFECTED." (five tile'num ber of water <br />wells affected or threatened, if known. Provide the name of the ground- <br />water basin underlying the site, if known, in the space provided. <br />10. COMMENTS <br />Use this space to elaborate on any aspects o; the incident. Conrnents on <br />cleanup work or planning or related investigations should be reported on <br />a separate Cleanup Tracking Report. <br />11. SIGNATURE <br />Sign the form in the space provided. <br />t?ISTRIBUTI�JN <br />Nand deliver or mail copies of the form as follows: <br />1) Original - Local Agency <br />2) State Water Resources <br />Control Hoard ' <br />Division of Water Quality <br />Underground Tank Program <br />P. 0. Box 100 <br />Sacramento, CA 95801 <br />3) Regional Water Quality <br />Control Board <br />4) Toxic Substances Control <br />Division <br />Underground Tank Program <br />714/744 P Street <br />Sacramento, CA 95814 <br />51' towner/responsible party <br />