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<br /> _ - LLak suspected at siL*. but, h<.s not been ccn_.rsec
<br /> indicate whether emergency response personnel and equipment wazo roto Sed oiknlan amityt_.
<br /> a; arsy time if so, a Hazardous ;auerial.. incident Refoort, slsa;x"Ld Ev filed requested of/submitted ;sy responsible par,v to deter.:aine wx.ethe vg.vund
<br /> with the State .:.flfAce oEmergency Services (DES) at, 2800Me a;ao-wv ew Road, '. water has been, or will impacted as- ..
<br /> a alt of the release.
<br /> S_cr anentc, `A 95$32, ',op>ies of the GES report form may be obtaa.aed at I'.eia;n mnaJ t. fIsessnarn, Y dnrnwayz'ler, s.ar„:n
<br /> ,nta . of wozkpl_an.
<br /> our local.,undergrouznd storage tank p�e.m tting agency. Indicate whether Err}s tine t taxs, ton neAon - responsible party is in the process of xa.',y
<br /> C„d report r _, defining >:x ..t c_ ,,.s.t.. is.w ion ___ ,is. v_a urcaar- mater and ease,ss ng
<br /> .e�<„° ;ra�.u. ���e.w a._ :s£ t.w c.ate of this r:,par,;. g ,.
<br /> �n
<br /> ,
<br /> .lar :t. (in ,<._f,nc _ a,'rd oir gro',A.._t at,exr,
<br /> pY �RY ��qT
<br /> a ry r ti. pti n 3'. ,s c r FlEa - rww&ation a:a.an s mie . '.a lzcp, :ere
<br /> To avoid duplicate notification pursuant to Haalth and Safety coSection rea,--d<.ation opt.zms. Pioposap. and :My .�• t, _ra _ahodure for appropriate
<br /> 25150.5, a government employee should sign and date the fo= in thin blacit. remedd p;tims also submitted.
<br /> A esgsnature here does not mean taxa, the leak: has been determined o t.ose,a 1_a:a r <v :xa„;x.exaf.;:a :tt oan of _emed n -rn plan,
<br /> significant `nareatt to hThn health on only that ..st.f:w oi..: Hoer .'toxat,3s ..... rz erio.rlic round o neer or other,
<br /> .,xc-y, atie. Rte
<br /> procedures. have bei.. followed if requixot_., rr.u_i;oring at site, as necessary, to v i, iy and/or etaluate effectiveness
<br /> of remedial_ activities,
<br /> HEPOR
<br /> TED It Case Closed _. aWna l board end .oe.. agency in concur_a=,,e that no
<br /> ter Your name telephone nunmber, and Indicate which �i,y yo',1 further work is rece,s ry at no site
<br /> resent and provide company or agency ncatne, i�p
<br /> 3.:.2;AM': _tE _;,1�OR,'I Tlcf' PROVIDED ON TBIS 1ORP', IS IINTENDED FOR GENEIL,'I..
<br /> RESPC)��57?3tE PAF,'1'Y ._'IHSS.; AL _,.JRPQMS ONLY AND lS NOT TO El., CONFIRMED AS I!,,'PK..`;ENTING' THE
<br /> h.
<br /> r,i er na7ri.,
<br /> telephone e *numz er, contact eisoax, and address of the ,, -
<br /> afty OFFICIAL POSITION kms' ANY GO'VE NMENTA. AGENCY
<br /> responsible for the leak. Me .responsible party would nozmaIly be the tan
<br /> owner. Rl.MI D5, aC"`IC 7
<br /> r adto Jnr- swc,-a have own ens<.d ;o .an .,i, o. remediate ,;?:w
<br /> leak,
<br /> STYE ITO)CziluN Descriptions, o f
<br /> optiona follow;
<br /> Enter i,Lormet_on ren d:P.g the tank faelliciy. At a miniea,.;n, Coxa a,,,-Wt
<br /> provide ,he facility nave and full .
<br /> addrnrr t�pa Site instal noxiz=tal. is?ten ale layer to reduce rainfall
<br /> uN
<br /> infiltration.
<br /> It,PLEKz-N`iTNG AG-F CIF Gn.t<._.Wert BWrQr - install veer ioal' dike to block horizontal moviment of
<br /> Enter nwres of the, local agency and RegionaL xNate3�. Quality Cont-rol Board r<ntam_oan't.
<br /> naa3.ved. S c .r eax�< f:r.sza .^ - <.n.o e con-,auainaued soil and dispose in app-t,„,ed
<br /> site.
<br /> SUfs TANCi?S INVOLVE'i.7 Ew"W_me and T--"�ew'at, - coHove contaminated sail_ and great (i.r.cZ_adea sproad ng,,
<br /> Enter, the name and quantity Cosa; of the hazardous substancecyrlvead, Room or land farming),
<br /> .s provided for information can two substances if appropriate, if more than Em"ryyyy Pg;duct i<.move `loating p. .duct, from water :ales,
<br /> two substances leaked, list the two 'if most, concern for cle_>nlip, NT , and Cr ._ "..«.rnd:mter - generally enp^rloyed to remove di mow.>ed
<br /> c
<br /> JZ»UVFhYfA3�T t1:.ha Esz.,,: _ �w i. ieni use of any ay.._l<at..e technology to prox.otc
<br /> Provide _nfzrrmat,icn reg _thief, the discovery and eabaLe est, of the 1._.xl=.. �;.eteria, decomposit,on of contaminants,
<br /> R z 'ac 11 provide alternative water supply to affeced
<br /> ,`iWCERAME e SEe t a ?"Am; - install Yater �Lzeatment device,, at each dwelling or
<br /> z.cate .,or,rcCs) of leak, Check box(es) indicating cause ot” le.alt. other ply e, of c a
<br /> nr c a n Ext L use p?e os or bicw rs to dray, a , through sa l
<br /> HSE P Pr.' Vont oi_ ta.a e Halos in soil to illcw volati.ldzaion of contaminants.
<br /> ia.dicit.e the case type category for dries lea.::. Chaok one buy only. Case tpa f,t+.t _,e<r?fired - incident is m dors rrequ,.rin& no remedial Uwn,
<br /> type is based on tile:nicest sensitive resource of f ec';,eu. For exaaatak,„t, z'f,
<br /> both,soil and s .ound wa'-er leave been affected, case type will be Ground CO' P,s.'S Use t.h. s space to e abo ate, on any aspects of the incident,
<br /> slates". indicate ':,>rinkin-n W"ater" only if cam or more mmiAnL or
<br /> domestic water well” have actually beer- affected. A "L round We& SICN, rrl - Sign ,_.e form in :res space p=er...ded;
<br /> designation does not imply .that• he .affected ,ager cannot be, s not,
<br /> used f w .
<br /> it prsixag water, brt<t only thatu wator wells have not 'yat been
<br /> affected. it is understood that vara type may change urian further if Me fmm is ...,,n.p,ie;ted by the wfaik owner .r -lis a8en , retain the ;a L -spay
<br /> investigation. anu €orw rd tine remaining Copies i,.:.<:ct to ycur� _ ca:w targe parmitti_ag .�,eenc}
<br /> fox d].strib"mic'n'
<br /> C`r trt.l°`i' x xaT�eS1, Origa.na- Local Tank s'eirrttin, t ,c'my
<br /> Tn icate the category which hest d escr xes the current status of a.., ..ase. 1, ._...,Lt Waa a.r ,te smrcea Con.:a 7W Boa-,,d, . a. ia-on of Clean Water
<br /> y
<br /> Check care b:aa only, z, � .csz.,a�i,..e �,'fe.s.,lssaa; t...�a?;i.ve >,_; i,i„a ea;>s ,ren. ,... Underground :.ro.a��e I'aua; I`_ t� �r
<br /> Y. .._. b � i.L:.., .e_.„ , S.e,.....:ktI.� c. , .,... 1 r,-;�—
<br /> ..�,._ if e type is "Aw mei Wat p r ,h.ea �_._>enx ” 'St...t..,. ai >1,.. refer 2120
<br /> 2
<br /> .r
<br /> to tete i..a ns o: the ground nater- ii n„„"ga'_on or _le'anup a is.c. ...i '=:o 3K, .,.?.t„
<br /> flea, :a..r
<br /> Hca l.' c ,c.xw ,_..ns of o,`, .c.nN fwr:.lc;cb: <r� ;n.r> t7f:. ., ,,
<br /> ` -- -n2 d..tz L �,at„ .c.sard �. p1,..w„ an t.s:;.... deeinee t:u
<br /> r No a"Un has Kezi taken by remonsAile a__.,<
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