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IN STRWICT IONS
<br /> FRGENCY Leak B3 inA Coni"irmod - Leak suspec*led',at site,- but has not been confuted,
<br /> Indicate whether emergency response personnel and equipment were invol,>ad Irelim'ina S%te Assessment:Workman Subr^s.ttsc< - wr knl.an/pruposal
<br /> at any tame. f so, a flazardous ter al....Incident Report should 1e ,`sled requested of/submitted by responsible party to determine, whethef ground
<br /> with the State Office cif Emergency Services, (OES) a`, 2800 €Meadowview Road, water has been, or will be: -i acted as a ;result of he Welnaae,
<br /> Sacramento" G,A'95$32, uolaies of the CES report, form may be obtained at= P e Am nary Site Asses nen" 'ander,ar - it lere,.tut, o;a c sa kpMar..
<br /> your local underground storage ,,a sk permitting agency, Indicate whether Pa?trxtion Chas acteri2.au?en - mesa, -sa t?e party Is sr. Biro eWs of fu,ly
<br /> the OES rotor, has bay,_ filed a of 11. uaLc f this repcxu, deflUing; the sxtent of contamar.t'tion in sot,. and g_c.azu watt and assess- g
<br /> Ls on
<br /> surface and/or ground water.
<br /> LOCAL &GEIRCY G;du Erma !at..csn °tan - remediation plan u'bm..tted evaluat-ing long texzr,.
<br /> To avoid du-a icate notification pursuant to Health and Safety c.;d. Scctlo a remediation onions. Proposal an :r i.., .?.t..aw mai ...la e for appropriate
<br /> 25180,5, a government employee should sign and :lave the fo--;n in this blocx-: remediation options also submitted.
<br /> A signature here does not mean that the leak has. been determ-fined to pose a Cieaca+ C:;dei*wav - implementation of remediaticn;plan,
<br /> significant ":treat to I�ucnati health or safety, only that notification= Po.�, „'`a.eatn: "�tozszt,oran ase irrc-r res pericolic ground water o� es
<br /> procedures have been followed if reg$.z _ed; oro it'Drir.g; at site,, at necessary, to verify and/or evaluate effectiveness
<br /> of 'remedial. activitAes.
<br /> REPORTED BY Case lasel - regional board'ax?d soca agency }
<br /> �� zn aor_cax;rz,,.e to no
<br /> Eaater your mime, telephone number, and address. Indicate air ch party you further work is necessary at the site.
<br /> present and provide company or agency name,
<br /> IMPORTAN : THE INFO MATION PROVIDED ON U91 FO � IS INIFdL'LIt FOR GENERAL
<br /> j PONSIBLF PARTY STATISTICAL EIMPOSES ONLY AND IS NOT rO BE CONSTRUED ::S EERESENTIN Tg
<br /> Enter name, telephone number, contact person, and address of the party IFFZCCAL POSITION OF ANY DOVE e;TA1 AGENCY
<br /> responsible for the leak, The responsible party!would normally be the tam
<br /> owner. hEftr 114 ACTION
<br /> Indicate which action have been used to cleanup or rearediate 'the leak.
<br /> SITE LOCATION' t escriptioxas of options follow.,
<br /> Enter xaiortaatirar. regarding the tank facili"y. At a minim;zi, y u amust
<br /> provide the facility name and full'addres✓ Oa> Site - install horizontal,imperiaeable sayer to r..d:ace rainf ll
<br /> infiltration,
<br /> IMPLEMENTING AGENCIES Containzient Barrier install vertical dike to block horico.atal raovemenb of
<br /> Enter names of the local agency and Regional Watt Qza].°„,
<br /> Control E?oard c,sx.tar.i?zant,
<br /> involved,
<br /> Excavate and Dispose - remove ;ontaminated soil and d s o.,e in app. z.,vod
<br /> site,
<br /> SUBSTANCES INVOLIrr.,Ll c <a`, a71d Treat. - remove contaminated sobs and treat inc'-Utdizrxe<c.
<br /> r"
<br /> Enter the name and quantity lost of the hazardous substance involved. Boor. or lamed farming)
<br /> is provided for information on.two substancez if approprlate. If more: titan cssote Free Product i;emave f'loatJng product, fra;l eat u,.is,
<br /> two substances leaked, list the two of moat concern for cleanup. Amo and TreaW.Groundwater generally employed to removediissolved
<br /> DISCOVERY ABAT.Et,1FNT _nl ac d, „a i Ltx - iso o any a. , :aa :.e techx ,L_,gy o promo-16
<br /> :Provide information mega„disc,_, the d.iscovery and ab4 :siert of the leak," bacteriew, deeot;positi'on of contaminants,
<br /> R as e! Sr„gs 1v - provide alters ative water suppl,,y t,,) affected x,bit es
<br /> S23lRCEZr-AUSF install ,water t cal.,,aent device, at each d�clling or
<br /> *vd,ic,ate sources) o leak. . Cho -', `box{es) itid cati,ng raise"of leap Q.Aaer p ce of use.
<br /> Va , am "Ex* e a e pumps or b ower a dreaw air thacts PE _� t :3c. ., fore hales ase c t ai.' sr zoa,aLsi za un rat r lax. Was s:
<br /> r�cicate the case type ,.tet;. y `:mss this leak. Check one box only. C se No A.t, on s;,!(Yu rod - lnc:.dent u minor, eruirinf. no >z 7_ aG z,�tr,
<br /> type is based on the isoct ,aeras:.tive resource affec'ed. For erau,:pw_, ..;_
<br /> both soil and,&round water h ve en affected, cas"e type will be 'Croune £`:)NME _'S _ Use this ;space to elato:ate on, any aspects of the M.z,.zceaat.'
<br /> Water:". Indicate "Drinking Vater only ®f one or more municipal or
<br /> domestic waLek wells;2aavezc real ybeen affected, A "Ground 'Water" GNA.?` _e.n fzs form'a.i thra;^ekovzeted.
<br /> designation o;a c{ sYs rot _ gr,°y that tsae affected water cannot ;fir-;, or is not,
<br /> iar S r t
<br /> ' T,�_�Z_r,..t
<br /> used Ede drinkingwater, but �,n�y„*.x.z„ ,�s,er wells hale iso” yet been _ __,.11
<br /> after+ d, It is understood that case type may, 'range upon furl"her f the for i m�,i ei by the tank owme:: or his ascent., _retain '-a last copy
<br /> xaareNu ga`zcr,m Ana f,rv.�rd, t,�. � raii Ing tcopJusimact to you, ,.ocal tsnk persdt_ing agency
<br /> ., ftfm =,..,1_�.U-
<br /> 3,-1,,
<br /> ,__a's n i. Tana:Fs.r ,.tt r,, ,.,enc.v
<br /> Indicate the category which best aascr,.1-1,as t,-- current status of .t__ '.,ase, "tate Watt- S�•zources' Coni ro'- _� ..d=, _,.:moi i_ „f Wet, .
<br /> Che,,k one boxnri. h, .es, .>_se a ba x_tat-iv„ o the case tylia, razz' Uni,.,gioua_,. StoirAla Ta k r _am,. j.o., 212, _a.. ,u.., 9124'a--
<br /> -,
<br /> xraraple, if case £ype is "Grounci WaL s . tl.en "G z2_vrw S atu. 'shQula �(_fer 212.)
<br /> to the _tatus of the round-w.. ,_a n � � �
<br /> .". ,. ., � =�wuaU_._� ,>� c._.�rt... z.w >r� � °� 3. r,.c„a„8. u�::.r Go,zt; uo.
<br /> that of soil e., ar oa> �:cp, Local ?t: ,.i ca., and Coz.xt, ” art( .f x s., <;
<br /> 0
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<br /> s _ a z ion ('C ._e°t if`- e
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