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<br /> 7-
<br /> MSTRUCTIONS
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<br /> Leak st.sz e red at are„ bul been `.°irmed.
<br /> wl .z2ez em +ge,:oy response personnel and aquil e. r.t ere iz;Tiolved � S to Ass _ rt > W .man Subm tt.: - aG., -o 1_r a,al
<br /> t aan irne. It' so a',.az.a dons Ma:;er'al incid .t Revert .should be; fi?e't „ ,i 'oUsubmittod by, r on5il l e w,ete whet, azo ?na
<br /> wi.`; n._ Stats `ffice of Emergency Serv`ces (OES) at ZU�O Meadow ,iew Road,. w.n e. 'Ile-- liesn, or will be, impacted ras a result r,. ., e1,,, ,
<br /> ,P 95832,
<br /> ;� <�rer2,., a.a s o t'to.GE��".`ie ort form ma br rt �, at Dn -.
<br /> p r �l�r �.Site Assessment I � �- �
<br /> your o a u aaer
<br /> gEo a r ge tar l>c Ana t tag agency. Cn c w;a wz e'ner To1j7,4j n tz racteriz ,.r.�, r�s .rrz 1.e party is ..., e,<. ,� ."t„ fiaLl:
<br /> ..,g= Gl°S �.e,.o.�., haseW_A .�ited az 'of the date of tb.isra,l.oz;t., faextent of conta.. _ration io soil and .... --ate- .,rd a.,naezz=.ing
<br /> a zz of pt.e a�zcilor ground
<br /> LOCAL AGENCY MUY. < � zz n di e Plan - romediat, az unmet e e jai „ xr
<br /> z c avoid dtnp? c t e ,tF a c tion pini ani; to Health and S ai tv c o;,ec n ren.edit t on options. Proposal al .a E zs 'exn _:uumz�n .,... ..,. £.arm „gate
<br /> 2S3 0.5, a gov„x,nilaen, a p s `�
<br /> E.-xyc� she i_d �.lBn and data t2;a Eery,; in Was �roask. x rac�?i ` cr`options also suh .,tkt
<br /> signature here 'ciar nsmm n, an aft the leak-has tuez: tcriairne I:{.ase <a C a .E ' d._ w"v - irl, emiwn a,? c_. .:emeefi L.ons
<br />" nificanat .
<br /> �, i
<br /> fl. t2areat Sr .Fan eats or Safety,. pr1. u>xat n icw :frtn Post ulorato.rx €; i�z mz ss r r die Fro-.., r r
<br />" pr redures have 1-5cPan followed if requ }ed. - ;a- ,.at site, as uec ssary`.. to verify a d,for _ effectiveness
<br /> of r m rr activities,
<br /> REPORTED BY
<br /> °a Ca < C s regional boa d and local e tba �ra
<br /> agency i,< Vu -
<br /> arzuer your nam elrpho.e nus-ber', and address Indscate whi,,,a p rty yo„g, urt:ha moria is nec-e say at tl t,s.
<br /> represent, and pfov4de company :or agency x a e.
<br /> IMP TA :' THE INFORMAMN PROVIDEED ON THIS .y ,tt !S, T FOR, GENERAL
<br /> EGF Fi^ PARTY` S iAT-i .�_3 i a POS 5 QRLY §tdl3 S Pd 'T'T d _ iC) ?"'SENT 4a1W
<br /> Ez.ter name, teipp nose noc,be:, centact person, and address of the party CFFI--1A, POSITION O ANY GGVIRNIME�Tt1L A—ENCY
<br /> _ ;
<br /> zespo11,>_ le or'tbhe leak The re"s>3onsibile pare wouldnormally be the tank +
<br /> owner
<br /> andr _te which a-t ozn have been sed.te alePnup or retic. .� the weak.
<br /> SITE L3CATTDN Disc p€ ctn., u,: opt.ioxs follow: ;
<br />,.
<br /> Enter information regarding the,tank £acuity. At a ;;ni.aatm, you mus:..
<br /> ,r:ovide the facility rapes and full address. g...
<br /> bl 1
<br /> s Si F
<br /> axsta<1 Tc az,r tat. i er e r'L layer , a'I . .:c.,reinfraI.),
<br /> infiltration, r
<br /> IMPLEMENTING tl a a: r ar, .zacr er install verti°ai d ke to ` ;not<. � r.rr;;a? na�v-,vajc tt of
<br /> Enter mmnez of the '-coal agency�id Regwonal WateW Qsal t y Control Board co,L m n t,
<br /> involved, �. E-cavatte remove Conitam.natod sail a'd , ;in n""rovad"
<br />" UM ANC EdINVOLVED t � _ �
<br /> Y �
<br /> a c T Treat remove cozy a sna _i soil naiad wrf Iiao None ceding
<br /> Enter the Warne andhost`of th%, azardpus a star. e n•xrca.veo. Roon cr tan. .ming},
<br /> is provided for information 'cgxn two substances of appropilat , if more then Remove Free Product - remove floating product from :r_.,r t t.s e.
<br /> two substancesleakelisfi .the �
<br />- two of most concern.- r c nap. f�.m a a zi3 m-eat Ga�oundwa9 er generaiiy employed ued to .�a. fi. a,
<br /> contaminants.
<br /> DLSCOV R/ABATk,NIEN'1' Fah az ' 9iodew n use of any av ilab'_e tech- :;�y to wLrc�cat
<br /> Provide information `-e xuding thb.discovewy and abatement of the leak. bac e,nal decomposition:of contami.nanta.
<br /> ,..
<br /> Ref-ac_ y ._ provide alternative water pan ?y f t t u: res.
<br /> SOURC- CAtTSB Tie�tmen, at 13�sokup instal
<br /> water treatment ue iu _., each. dwe7lnng; or
<br /> >ndicate
<br /> source(s) of leak s-Check box(es)-Indicating,cause of leak. other place a use
<br /> azutta -_a use pumps or blowers to draw air thfscv t
<br /> CASE TYPEVent Soil - bore holes in soil. to allow volatilirat
<br /> ls:clicate the case t e
<br /> Y :.a� 3ay ci tlazs;leak.,: heck Ln pec v. ease o 3c R. aced incident is minor, re ar ng s.. r a t on.
<br /> ,, r
<br />' type is based on the M-6-si sensrit i'tre resfssy oe of ec ed.,^ ar' e
<br /> amp- , if
<br /> both soil and ground astter a4e been aff�et xi, case typo Y14,1 be Ground C:OFMENTS 'Use this a�sceto elaborate on any aspects of .. z, zn,,,den t.
<br />' Water'. Iridicate "tri.king Water" only it one or more municipal or
<br /> domestic Water wells five actually beers affeofa,a. A "Ground water" S GNATUR - Sign the .St rrJ in the space provided,
<br /> lc:signati ar does r c=t i r i.y t Za9 ie affected°dater &annot..be, or is not.
<br /> used for drinking water, but dnly,that water Wills have not yet been DTS__.1BUT1Qls"
<br /> affected. It is understood that Case type,maj change uppn".further I tine fora is completed by the tank owner or his agent e las4 copes
<br /> investigation ' _, ax.d £crward the remazz}inYg copies "tact to your ,Local Look tis__:g agency
<br /> f:a di,>-,-ib t
<br /> C1RRENT STATUS 1 Tank ne mit i„e.ac
<br /> r
<br /> Indicate the category w ich best. d"cribas the cur.rent'�staczsof the case 2. � ,eWaterf?eso=,�rc�es.�vOr Board, Division o£ C. E... '..auar Programs,
<br /> Check one box only. 71ab resp6nse should�e relative to the case type. £ox Underground Storage Tank Program, P.Q. Box 944232, %%; 942a4-
<br /> examcle if c ae typo l s� "Ground ou.nd 'e_",',tiscri 'ACuzra ,a :.. ,as should rofq 212
<br /> „ _
<br /> to the talus of the pro nd w=ter'i vesui';ation or cleat zpy a�. o,nrosed to i �3. gin'aI Water Quality Cort,ot Board
<br /> that of so-211. D_s.aii*6tIous of options ' Health „-,a -
<br /> follow; ;.' � z. . Locur ,d�.<_��_- t?ffa.c�r. and Cc:FµnY,p B
<br /> c,w� fi �f >,.pt.�,...>oa_ a=r .._ems.. d,.,xt.>.. ., to
<br /> 1? u
<br /> Preposition
<br /> Nva Action Taken - No ar_ ,ios: lad ._
<br /> be .n aI a, �v xa5k ns .�3.e ga a:�a beyond' 5. J�a at Fidt�y
<br /> i.n _a.l. ,eport a': M
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