|
iNSTRUCTIONS
<br /> hta U�hCv
<br /> Leak , s3E i ani Leak s 5pectw site, cut bias not been confirmed,
<br /> Indicate whether emergency response frsrsonnel
<br /> equipment wee involved Pre!,,,n v e 'u,k a 't e< kp asxlprrpoa aZ
<br /> at any r .f so, a hazardous t-lateruial Incident leper.t should be filed r , s rt:y to rae r ae whether, round
<br /> with the State Office of hmeneory . >ices (DES) at 2800 seat w _.wrr Road, water �,
<br /> _ „ a mil_ M „t _;
<br /> `s . result of Un release,
<br /> r
<br /> r
<br /> Sacramento, C 9583T Copies of the OHS ncpot Imm may be obtained at r Ind iWimart"Un of w ro
<br /> year local aroa rF rour-d storage rank 2 s agent- ndicau, oh—th— e z t n fully
<br /> the Gi report has H ed �s ^a
<br /> e ,
<br /> �
<br /> w the done e� ��. �spo.wt_ a a �r contamination t ca a r d "tate, +a.wl assessing
<br /> impam: on surface wd&r gromd ,a.a+
<br /> LOCAL AGENCYCS
<br /> xF
<br /> 'iatic)nL.n
<br /> d r
<br /> 1 avoid ( .l ate ,oTifstfon p, r to aea_ � and Safety a Section, z ea and implementation caed6,tr x anwpriare2w1,. . a goverment e,picvee should .-sn and date thefoxes in t, mc a,eck. rmeu_ Mme. , z . _,s. s€b :tc:a,
<br /> A,signatme hers Q€€QMI not moan t_,at the leak has been determine to rose a o 3.-.at,ion »an.
<br /> xrn a t' rest to human health on safety,
<br /> . < �afty, only that notification
<br /> r
<br /> � periodic ground water o
<br /> a otter
<br /> ,avc .ree s�lrodec if rtairac. aL site. ,, necessary, to .er_ < �s�nr txa't< e sf:ct
<br /> eases
<br /> board a genes 1n _ u ar a.-
<br /> Ln u phone number, and aAress, Inducte which i,. ty yo;-, x...,..,., r t the ._9o,
<br /> p como .y or agency n-me
<br /> nZ L
<br /> ZT A71ON rE r -
<br /> t� - lug C ,t=
<br /> .....__. _ k s d 4
<br /> - � h � i ��` �i �C` 2,� THE
<br /> rr� s_ u�, :tet Vim., sY, con`9-. sersen d diz , z,d �s _ J v u_R zw,�.,._,.. _
<br /> ti �__
<br /> be_p.-;... ..v for the .task, '.,,he responsible par:ty €;a�.td ros„aal.ly be, v>ae tu,_
<br /> owner,
<br /> have e-n used tocleanup or z.es aa.at.e the
<br /> yrs I Ckl t }e v
<br /> of fc l:,,v:
<br /> ,',Ler information regarding the tank facility, At a a,.fr>mut;,, yes r mars
<br /> provide the &.cj,,..ity name and full address. L > .ZCatai iffilleriscaLl-o layer
<br /> UTHATENTING ItI7 r'ES iaszaili vet"L`,it..l i'.ae to b4a AmimnUl_ ,,art of
<br />,
<br /> Enter s . a_ Y� local
<br /> agency and Wgional 'erwCezala ttr Cmysml Boma, E
<br /> .�?1? Vz CU- .aa.l4,.,,.�„.i.it n 'x.,3,„*.,; _..
<br /> _s.... _..._..,,_.....65....,..,.:;„ ,ow 1 and d, _ a si p..,a r e
<br /> e
<br /> S r n , rrT E m ., cntar__.a,ed soil .notreat
<br /> Uncludes spreading
<br /> Enter the name izft� quantity lost of the hazardous substanoe invo�v"L, Roam an land _Lnvo
<br /> s pkovideed far information on two sWwtazwes if anropmate, If move t-Mr, _..._._ emo e floating product from "r,a`r�.r _abjfs.
<br /> two soh to ees"laked, list the two of most concern for cleaztup< � mn,....r ...` r f uaoralt aapl€�c r=n -remove
<br />€ �.
<br /> x
<br /> Provide ,.muzz_t.L,. _ egu=aing the discovery €,-;€u abatement of t1ae i kof
<br /> to _a.,.
<br />� oitcrnative
<br /> c
<br /> SC
<br /> - ti w_... water v.._.,;r.�t E, r,
<br /> ,-,,f Y Lcar�', check ox..es a a.,,�.cz.r_°ao NatA uv. -.
<br /> °a �.a s._ _v a s _ .>�.h doll..
<br /> ;
<br /> am! to alKw
<br /> aQUzAron of
<br /> wWama
<br /> dicV,n-
<br /> a . �z,e �e type r.,atea ry for this "eek. Ghv r n, box as, ±:. a ��54 � � a as t
<br /> .._..�._....,,.� s.,M.,.., - -
<br /> ,tea .,.y ..,.
<br /> uycsa t ��. s°? on, the zaxa,>i; sansiti�re r,a��nrce affected. ?°cr exa�€�, a to r _ .x,� � action,
<br /> both scal ond Around watch have bmn allm,Wd, :.ase type wi11-Xbe "Mama
<br /> ' �. _.. latorate cm w;'ty aspects the _a,_de
<br /> 2 Wate` , w.,,,.. ��_..6ing WWer" only if one or more municipal ,,,,_ _ _ �w a',
<br /> donnesticactually nen -affected. A '`C,round Water' EPy€ g `tea.n t... fes__. in, the space rr,..'raded,
<br /> 'e,,..gnatim Neu res implythat the affected wale-, cannot be, or is ._
<br /> used for dr'AAZ w4mr, but only that water welIs have not, yet been a
<br /> affected, it, ic understood that case type may change upon further If the fm . is compleved by thetank owns at his agwt, .a_w;n she fast copy
<br /> n4,.st a _-.x.on, ,. rrd c ,_._6 on ret .a.t,ing CoPies intact to your Local anl, psranittJ", c
<br /> «-_ m-sW,__,,.;
<br /> VAgir
<br /> Indicate >_ cawgory which hast describes the current status of Um casm 3. State Alat-ar Resources Control Soaro, ., ,,_Wo? of C,-oan Water Programs,
<br /> Chenk one box m17. The response sic .z?i be relative to the case tne. For U nde a,a =. SZ.: x k Cµ. Uam, PA. Bw 9442G, Sacramento, CA 94244--
<br /> example, if cace, type is "Ground Waver', then "Cur_ ent Status" .,ho c r,fer. ?i2
<br /> r to the status a f' he ground water it es,._sad=den or cleanup
<br /> as rlpaM_.i to on al .a"vrr vsxtts:aw Board
<br /> Shaw of. curl, Ddscivip ms of options ."shows Lmal r;,.E.,.__ O.A,er and Cmmty BoardS z s t
<br /> . _ _. ...- mate.. to
<br /> n"KicaLimm.
<br /> No 9 Y-�_ on -
<br /> _,. its action Las ;_ry.:: taker by rc".Sj30Y7.1..}164 Y3a.i.y a?'.?j.-sa s
<br />
|