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INS TRUCIiON
<br />Eu,:.RGE NYJ
<br />CURRENT STATUS
<br />Inriicatr emergency emerency response personnel and equipment were involved at
<br />Tndicat the oat.eyary which bast describes the Current status of the case_,
<br />any time. if so, a Hazardous Materia? Incident Report should be filed with
<br />Check one box only. The response should be relative to the case type. For
<br />Che State Office of Emergency Services (OES) at 2800 Meadowview Read,
<br />example, if case type is "Ground Water", then "Current Status" should refer to
<br />Sacramento, CA 95832. Copies of the OES report form may be obtained at your
<br />the status of the ground water investigation or cleanup, as opposed to that of
<br />localunderground storage task permitting agency. :Indicate"whether the FOES
<br />SGiI.
<br />report has been filed as of the date of this report.
<br />IMPORTANT: THE INFORMATION PROVIDED file THIS FORM IS aNTIENDED FOR G NFERAL
<br />LOCAL AGENCY ONLY
<br />STATISTICAL P'URP'OSES ONLY AND IS NOT TO BE CONSTRUED AS REPRESENTING THE
<br />,o a� id rupiie.ate notification pursuant to Health anti Safety Code Section
<br />OfiFIC1AL POS iIC1Pi OF ANY GOVERNMENTAL AGENCY
<br />25180 a designated goverment aiployee, should sign and date the form in
<br />this black. A signature here does not mean that the leak has been eeterlsined
<br />REMEa A" ACTION
<br />to pose a sinniPicant threat to €ima health'or safety, only that notification
<br />ndicat whi di�actions have been Used to cleanup or teix.diate the leak.
<br />Descriptions
<br />Y`flcet LfUY°eS gave been to]!owed if required.
<br />of. options .follow: -
<br />REPORTED BY
<br />C '._Site - install horizontal impermeable layer to reduce rainfall
<br />Ent, r ycrllr -'nawc, telephone, number, and address. indicate which party you
<br />e fi?tratior:.
<br />represent and provide company or agency none,
<br />Containment Barrier install vertical dike to black horizontal movement
<br />ESv Ci,tiidi`if rr'- t.
<br />RESPONSIBLE PARTY
<br />Excavate ani its Dispose _ remove contaminated soil and dispose in approved
<br />se
<br />r n ne> tare: ` )) , 4 n tt r 'rsor" .net address of the Party$
<br />d.........______.._
<br />ta.
<br />..;p, carafes Th , ,. pons.hle arty would 1 nor aal7 de the tank
<br />Excavate and Treat - r^euiova, contarrirated soil and 'treat ;includes
<br />"...r,?}'d
<br />ap+, o ' it g Ear I a r n i n g -
<br />Remove Free Product - romove floating product frarr water
<br />5"T" [ CAT -ON
<br />to:fie:
<br />Enter tn`T6rreat=on rt=gar dnq the tank facility and surrounding area. At a
<br />Pump and :rcat Groundwater - generally employed to reslove dissolved
<br />minimum, yen must provide the facility name and fall address.
<br />FoFFE rants. —
<br />Enhance£i Biodegradation - use of any aysilabie technology to promote
<br />€Y -'%PLEA N:INN AG NICIES
<br />baoteria dacvmposition of contaminants
<br />r �" ^€al agency and Regional Water Quality Coystrrr€ Board
<br />re name f ,h.,
<br />Replace `,uptiiy -provide alternative water st;,,laly to affected
<br />involved.
<br />parties.
<br />Treatment at Hooku1n install seater, treatment devices at each dwelling or
<br />SIBS FANCES INVOLVED
<br />other p7 ace or use,
<br />.._ a
<br />Enter th?E name as.ai p,.ti :y lost of tr,hazardos substance involved. Room is
<br />No Action Required - incident it minor, requiring no
<br />-
<br />provided for information on two suhstan:es it appropriate. if more than two
<br />retial action,
<br />subs.ances leaked, list the two of most concern for° cleanue,
<br />COPtMEN S _ Use this space to elaborate on any aspects of the incident.
<br />S£Or RY �Ai A [EEMENT
<br />STGUTUtdE_ - Sig the form in the space provided,
<br />r vide i fo ,i.,tror regarding the d >co+ery and abatement of the leak.
<br />lO
<br />ii �iRdil,Nl
<br />SOURCE/CAUSE
<br />It the forms is completed by the: tank: owner or his agent, retain tete last,copy
<br />Sn t(at°. sours ts} of teak. provide details on tank age; capacity and
<br />,arid forward the remaining copies in tact to your local tank permitting agency
<br />material if known. Check oox{es' 'indicating cause of leak,
<br />for distribution.
<br />I. Original - Local Tank Permitting Agency
<br />CAST: TYPE
<br />2. State Water Resources, Contrail Board, Division of Nater Quality,
<br />Irrli.,ate the case type category for this Teak. Check one box only. Case type
<br />Underground Tank Program, P. O. Box 100, Sacramento, Cit 958 01
<br />is based on the most sensitive resource affected. For example, if both soil
<br />3. Regional WAter Quality Control Board
<br />and ground orator have been affected, case type will he "Ground Water"
<br />4. 'County Board of Supervisors or designee to receive Proposition 66
<br />Indicate `Drinking Prater" only if one or more municipal or domestic water
<br />notifications.
<br />well,. have. actually been affectod. A "Ground Water" designation does not
<br />S. Owner/responsible party,
<br />isr+pl,Y that the affected water cannot ?ie, or is not, used for drinking water,
<br />but o ly that water wells have not ,yet been affected. It is understood that
<br />cases b1po treaty change upon further investigations
<br />
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