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iNSTRUCTIONZ
<br /> EMERGENCY Leal Being Confirmed - Leak suspected at :site, but haz not been con`_i rmed,
<br /> Indicate whether emergency response personnel and erp:ipxaent were involved Prelim'nar7 Site Assessmenr. workDlar Subrztt.,d -'wo h_».an/proposa,
<br /> at any time. I so, a Hazardous ons Meter al: -n dent Report slxau.ld b.e died re nested of/su mitted by response le party to determine whether grassnd
<br /> with the Stats. Office of Emergency Services (CTS) at 2.800 Meadowview Road, water has been, or will be, impacted as a result of the release.
<br /> Sacramento, CA 911832. Cc.F>ses of the GES report form may be obtained at P LLssiinas'v Site Assessment UnderwAy - impie:ncnta oa ci` workplan.
<br /> your local undcx rfu,d storage tank erzn ft.x: agency, indicate whether Pollution CbaraCte-iZ,
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<br /> ion responsible paiy is an e nrsreEs of idle}
<br /> the CES relsort haz been f lc�d a of the die of h9. neper'_ defining
<br /> _ t?€e .extra t o c€-;�tat ninaMion in soil aurµ,g-rounc water arch aszessd1n
<br /> Impacts an surface and/or ground water,
<br /> aLOCAL AGENCY C 7 ai k median_con elan - rere.,iation plan submitted ted evalua _ long torm
<br /> To avoid duplicate notification pursuanty
<br /> a 1T•att° and Safety acSection i-erced ation cations. Proposal and kylectenta .�
<br /> ..on _che -_'.e or appropriate
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<br /> 251.84,5, a gu,e -went employee should sign and'date the form in this Blocs, remediation options also submitted.
<br /> A signature here does riot mean tha`> tate leak has keen deters,41 ed to rose a Cie rw Undcrwav - implementation of remediation plan,
<br /> signif_eart threat to human health or safety, only that, notification _ „? an a� t5onitdri in Pa res - pericdxc ground water air tither
<br /> procedures ha e ripen followed if requ red, monitoring at site, as neaessary, to verify and/or evaluate effeetiveness
<br /> of remedial activities,
<br /> RFPfI?2TE l ' Cane Closed regionalboard and local agency in concurrence that no
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<br /> rater your name, telephone cumber, arta add.--esus- Indicate which Pazty you further work is necessary at the site.
<br /> resent, and provide company or agency "lame.
<br /> IMPOP APRT; THE INFOMATI N PROVIDED ON THIS: `ORM IS INTENDED FOR ENEF-AL;
<br /> RESPONSIBLE PARTY STATISTICAL FUI SES ML,Y AIM IS NOT TO BE CONS:iUED AS REPRESENTING THE
<br /> Enter name, telephone nu.coer, contact person:, and address of the party CFF®CIAL POSIT,IO O ANY GOV'ERNMEMAL AGENCY
<br /> responsible for the',.eak. The responsible party would normally be the tank
<br /> owner REMEDIAL ACTION
<br /> Indicate which action have been used to cleeanup or ze.reuiate'the leak,
<br /> SITE LOCATION Descriptions of captions follow: '
<br /> Enter information regarding the tank facility. At a minimum, you crust
<br /> provide the faciLity nacre and fill address. Cats Site - instal: horizontal imperimeab1e layer to reduce rainfall
<br /> infiltration,
<br /> IMPLEMENTTNG AGENCIES ootalanment Bakriez install" vertical dike to block, horizcntel movement, of
<br /> Enter names of
<br /> Uhelocal,agca..ey and Reg_ona._ >vate_� GraaLs,ty Cozat_csl Pr--arc coa:,,amnant,
<br /> involved, raua�=ate ars isRcse reatsove contaminatLd soil and dispose in a. p_ ,:e^
<br /> SUBSTANCES INV,IiED Excavate and ?Teat xemove cont,aminatee soil and treat tirncint e., ..preaa ,,
<br /> Enter the nalce and eyaantity ort, of the hazardous substance :nva veci.:' Rom or land farming)>
<br /> is provided for information on tv;o substances if. appropriate, If a„o_ea ,,call Remove Free Product remove floating product froza water T>abl$•
<br /> two substances leaked, list the tato of ,rest concern for cleanup, Pumn and Treat Groundwater - genera-ly e plt ya t nem. v e ved
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<br /> c.,z ta%r.4nar„„ts.'
<br /> 4ISCCVEt;Y/A 3 .I9,h Y a.,;ed s_�-dcA_ad . ou use of any at .- abe technology O ;ro 3ote
<br /> Provide infer . w,ozz .:egar 3is g r};e a scav ry and at t_c...x.L of etc .eak bacterial derompositio_. c contain.nants.
<br /> Tz t c s ty
<br /> provide asterzative water suzplply to affected parties,
<br /> SCURCEICA N a t c .E - nstall water treat, em devices -.'each dwelling or,
<br /> dicafe so Xc i of leak, Lek.,bar(e5 ,nd' acing cacao oa . ay..e pl....., J t.,.e,-
<br /> Vactaim Ext use -,n or blow draw air throiagh soil.
<br /> ASE TYs^F -c _,rile_ so”, tc _.11ow volat,.lyzation of contaminants,
<br /> Indicate the case type catet,oa y ?'or this jes. , Clerk erk are box only. =.az r No Act4. v,z,red - s.,c idem _-' r nor, requ4rirg no remedial actIon,
<br /> tape 1'5 based on the nc,t sensitive reuoczar ufxer:ec. For pxar_p��-, _,
<br /> both so ? and g roun,., . r,;, kaar be=ex: azf`cc+.__I, ,a ype ar `4 U =€,:.t 1,14FN S - Use Ithis pace to e ab _.to on any asp ct of the Incident,
<br /> Water*'. _ttdi.cate "Drinking center” only l,T6 one or a:tr=re municipal or
<br /> s
<br /> domestic water well.,s have actoal:ybeen affected, A "Ground Nater” SIGN _ - Sig., _a form in ,.e space provided,
<br /> design=aL„csa does not .rFal.;t 't1,a.. th'w affected wu-ler cannot be,-or _., .;ca; -----
<br /> €zed -o< drin'king water, but only that water r: .11a have not yet . . n 'IS,-RBUTT IN
<br /> affectet, it is understood, rhat .,a.;c tyFxe ..y Upon fs.,tt._, ti ,*..sir; € ,t_e'ed b1 the _mar _- o his ageut _oma =.e .,ave .;a,yy
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<br /> and ` ._d the czr<sin- n},_es' na.,�,. to your, caW.�tank e x sit ta...irat agency,
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<br /> ...� r the i t��o-� �ist,.�. „emu �z=: , , _, t_,; s��_._act-- status, or u:. _:c. L. s>.�.. W a.,e Ccntio_ ?r,a,d; Division of e ., Ww,
<br /> Check ane ,>c=x only, ,he l:c,.oonse sh R 1,�e tic =z r case tyre, s, Undararound 1, n M
<br /> <3,rrl- -:. tw ,-,_c -a'p4 _Z� `Gr aa,_ 'Na __ `fianv 1..x.5,_ ..: ,Stator. , Le." r '.2120 -
<br /> to the SIat,,u5 of „•ie r. cund.._.__ i _,, a,_ _. or _'ear r, acs. oppo _ tea._ Cc-,,
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