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T iSi€€.?€,TMNS
<br />�CURREiT
<br />CERI.c.a6;t
<br />SIAT<ii
<br />,..... ...
<br />. tafii :a, t _' Wh,. #,er ax{r{ yt-'2i„?� f S€.€, ;Si � ,.;"5;}C#;i@ € dt€'� ..L tl'i yS<A .j`7 t; were ; nV<J J £3 at �
<br />17 n, .e,t# qor which best dE 3£. lbes the :urr€ i,' status of the Case.
<br />' i § � s,�
<br />a.xk; =4. 9 sv, £a Wazarca£t�s r,<atprlal Incident Reportshould n4> fal d =Wall:
<br />Check one box only. Me res;;drs' sta.,ld be relative to the case type. rvr
<br />the St§te {.f#afi�cer�f[.}}��))}jryryrx..rjen �r Sere,€..,s at'28C.0 "fead0wV;n.W Rad
<br />exi2#,..,'.i if 4# £' type .s Ground Wotef tHen ,.�Ekr='c'r<':. Stat,s" sh.ouIl9 refer to
<br />5
<br />"
<br />3i.,£,r.:
<br />?.:a E.na3{K'fy#Ff.'gpa J.ifA.>5.. ^lJ;)i fx,'�n t)i LiiL' i:LC : Y'e oro ff rit..(I#e$ t 45
<br />y ..e obtained -at your
<br />the
<br />W status f the fir£} =;a water investigation or c'ieanu , as ec3puse to that =.)F
<br />I c r ,r ota= d s trrage tank'" permitting ttin agency. . Indicate ;ate whether C)ES
<br />Yt
<br />so i i
<br />naport has been filed as of the date of this report.
<br />#�
<br />:EdlORc, ilSk(': £HlE 1,<FtiRM BION �'RIVIDED ON -WS FIRM S iNTZE DED FOP iENERAL
<br />"
<br />A �+
<br />f {^'i€. AGENC' Y.: �,<"s ..
<br />STATISTICAL i.'.r3i#. tEiFJ€jS :J L}:k sy ;t:aJ ..t. {'V[ tk :>L t..��'�3 #F1:1ED AS 'REPRESENTING, !£E
<br />la avo,s,{ l#ca e .a4,£f`:,t-lon pursuant to Health and Safety Code Section
<br />4..
<br />f>I^1"a., AL POSITION . AN''i G 0 V Rr''EN tf, fAGM'Y
<br />a onsi,knated rl)vern.mn4v,, to ee sholuld S#Or and date the fo na ir
<br />this Mock A si r#a.ur£> .re ., r 1 le nee.
<br />i# r9i£ay i'F !IC<a 't �a� 'r lf; jt£ has 3.; .,n £ :.Y€.!1. rS.,.
<br />RrMEC;yAl ACHON
<br />_._.._ _
<br />.
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<br />to pose ': Si qniiiCbnt tii#"E'a'.: t€) ?#,'# ar< l£8a'itn or aaiE:td, only t#.a`„ n€)t#4'iCr3.f`!?'t
<br />procedures have been followed i:l' rE u€uireO. � �
<br />r?412c � cihl4;h actions have been used to cleanff; or ,,emediata the leake
<br />tis€:°i .acts of��t<f;ns-.follow,
<br />R t'f
<br />C tel Site - in'stal # horizon+aT imper+mat+;. 1 ty�r to reduce rainfi3Ol
<br />r.i#tE your nam., telephone numtter, and address. Indicate. which Party You
<br />t �'. ttF-tr. -
<br />reoresent and provide company or all,ncy nam.
<br />Barrier _ install ver!:a.Cal dike to Mock horizontal. mveent
<br />.„,...:.
<br />,..
<br />6Y!it.aTtS,#an:%:
<br />7o-
<br />-
<br />Rp„Sps,.#Skdl-E flARiY. �
<br />Excavate and f3a 4#)Ci £' - ±'£}tOLrY {; Cillt<'.rli Hated soil and £#'€apfs5"' i:7 a#)jarGvets....
<br />nu,.iber, Contact lxrson, and addressof the :arty
<br />4 t
<br />r°�sknsihlc for the. Teak. - The #esnonsi(ale party would normally be the tankExcavate
<br />ansa great - rn#•eve con aminated soil and treat (Inc'ludes'
<br />.......__ ._....
<br />owner.
<br />,.`..
<br />---
<br />spreading or Turd farming). ar,=inn).
<br />Remove i•reii produ 7t - rellk}ve floatinf4 proms, from water"
<br />..
<br />,t
<br />SITF
<br />a
<br />.....
<br />f :.. rt .i, r aar-f ing th€: . }nk faci ity and surrounds rd- . At a
<br />rrJ. f' rZ 3-J€ if t#'n area,
<br />A q
<br />N#}#'i[} 4)n� #{.aL. ra in{a Yi'l teff .. ui{f;r4la ?;is ii)Vef a..t� ?.<p#s#:,*C'#5:}1L�4i
<br />�i nT?'urs, yet., must. provide, the facilit.i Yta?i?£' and full &£idrei59
<br />`.
<br />Enhanced I'I9t'@C�j r's;9'(,t Ctt - £a5A €;Y 3�'sY i9 Y:1^ldi7i2 technology i:.0. p'"L?;i;fii$f
<br />(P'[{?...t."{c.#'�!�!£.IT-fY J'�fiG'tl. T-„f"S
<br />..
<br />()a3.. A.8 i^�(i+ dC.'C43###¢i"31,�,x€}#i E'f S.E}'i t.S7lit Pl C'f:#t.S.
<br />cnt„r n,.n{;s rf whcr i,, --al axle an-giona# Water ual #?t,y Cf}, trs)l 'Board
<br />Repl<ac=, §#as��ly - providre alternative mater supply to affected
<br />- 4nYvl i�E!s.
<br />1)3x ties.
<br />TrLatme'8t a 1 -lookup - `install water treatment devices at each dwelling or,
<br />SUBS �`NCES Na -€LVE[;
<br />O..hf'r t1�d4.0 Cf f15.:..
<br />iann quantity lost or the k<iaz£rdouS $fYbsta?ce invo led. Room i5
<br />;tin Action Ri€uired tr.,0dent is minor. requiring no
<br />provided' for i.n forptiticn an two . substances if appropriate. if more than two
<br />re€ -gids al ai;f 7CC£.—.. __..
<br />substances Ieak-ad, Ifs° 1he.. tw ,f Imost c n-,8rn for ,.#:z?'3:i ta. - <
<br />w0MFFl�`C _ Use t;lis space to elal34)#"+§tt, on 7Y#y BspeZ''5 Cil` Ciis+ incident.
<br />i#1SC'3vERY rAE?AT ENT
<br />Pi^ttide !nf}y#,atffT# r'tsgt?t'€SiP#Cy the discovery 3tri BtaAte.€i#E'rt of the it'ak,
<br />ST"a4€'T. f Sign th£t forty in the space provided.
<br />p(,M§"(?Tca�k
<br />SC3'R,.L,_CAUSE
<br />If Ln8 form is completod by the tank owner or has agent, retain the 4last 4:4,).
<br />not it e.€$) i 1 3i:. it'f:YT:§C details f}t} taPl } £?;. G:Y:IGItY i}
<br />and forward he remain-kig copies in ta,;t to,}our local tank permitting agency
<br />rta`erial if known. Check hox€es) indicating Cause of leak,
<br />for distii;a,ts`on+
<br />1. #r.al- ?oC . rar;k pr i' i*t.i#, kgenoy
<br />SE T.y C
<br />2. State Water Resources Control Board, Division of Water Quality,
<br />_.._ —v
<br />t
<br />l�f3d aL„ t.fan 15,: type category {.�i)#'y fo' this Tw, K < Check d>'& f3oR only. Casa type
<br />Underground Lank Program, P. (i. Box 1S'', Sacramento, t 1 r5(lvl
<br />u zt
<br />y l
<br />a:i based Qii #'# r3i4}C sensitive resource. Cf[e�;. tQ�i�. F4}P' example, l� both soil
<br />?. Re,,#i4}nal gayer Quality Control Board
<br />J
<br />an
<br />g .z?ta 23k..?%ya,J)Cii£i
<br />4. County floard of Supervisors or designee, t0; rGf'i-,)e Pr000sition 65
<br />. .only
<br />indicate .:Drinking �a € .if one or t63 re `ii#^iC Lal or kJi?St'i+iii ter
<br />wells <l a actually t,e n a rc t£= A "GroundWater”designation .'.ri es ^a
<br />:. f.Nnerirespons#tl . party.
<br />j'£{7xsaty that the a,f;:cted water"cam,,>
<br />ot i?i dr is nod", used for drinking Wa'terr,
<br />tt tt only that water w l € , have nos, y t been affecte£i> It is understood that'
<br />case type may change upon, further investigation.
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