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EMERGENCY
<br />Leak Bean Conf rsicd, - Leak suspected at s.+a but has n.,v been rcn_`tra:aed.
<br />Lndicate whether emergency respozz o personnel and equipment were involved EL21iminary Site Assessment, Wo:kxrlar; Subm.itt eel wo kp.l n proposal
<br />at any time, I f so a `ffazardetis Meter; al Incident report should be filed requested of/submitted by responsible party to determine whether ground
<br />with the State Office of Emergency Services (OES;) at 2800 dowvi6ew.Road, water has been, or will be, impacted as a result of the release. `
<br />Sacraments, o, , GA 95832, Conies of the, OES repon form may be obtained x;tI_ e- „:r. Hary Site A :,as,a n..?nderc av i aF le.f.cnta`.._e,f cacrkpl.an.
<br />your local unde raund storage tank porm-itting agency, .indicate whether Pollution .,taraca_izpticn - restsonsib}e:a,ty is it, the process of f-ully
<br />the QFS eport has we,_,.r,_filed as of the date of this report: _ defining the ertect of ct:;+,.-,aasaation i.. soil aind w._cvz;Ut utter and assessing
<br />rg
<br />. ,... t.. Liz, ..,rf ctr and/or gr guild wa`l,er,
<br />LOCAL AGENCY (RU r media on 'Piin - remediationp1a: submitted evakxaaing,.long `era;a
<br />._._._,._.__.... W..„..,,.
<br />110 avoid ci zp .icat:e notif;.cat°on pursuant to Heal_th and Safety ;code S ctio, " era lief yuNa jti ns, € oposa_, ax?d re lu 4Yn,< ,.Jw, w ... e for appropriate
<br />251130,5, a government employee should sign and date the form'in this block, remediation optima also subriittod.
<br />A signature hare does not bean that the leak has been determined to rose a L-1 as.ap Unclerwav - inl,2ecrcr.tGat%cn of score i.at c }zla.f,
<br />significant threat tb but n health o: safe y, on'y that notificatio P .> CIC-Monftorw; ixz Pro;.e_ perwoclrc gr and r_`er or uthe:-
<br />pr cedures have been followed if'requix-ed monitoring at site, as necessary, to vezif'y and/or evaluate effectiveness
<br />of remedial
<br />_ Oactivities,
<br />REPORTED BY Case s a ig�cn��
<br />'--,card and '.see.'o;ex,f ..:o.,r�r:ce that
<br />no
<br />tex your mase, telephone tMlber, and address, Indicate vrach paxty you rE e_ work is necessary at the site,
<br />rrost:n and provide company or agency name.
<br />;MFCR`nN'T. TFE� `:FUMATION .i'P IDED ON ,..ia FOIRM is 1q FNS Ezn F R GMNEFA
<br />ESPt7NSIBLE PARTY
<br />STATIb_.,CA E ON1;Y AND TS, NOT TO J)sY?CONSTRME ,S REYRESENTING_.:
<br />Enter name, telephone Haber, contact gessoes, and address of the. party OFFICIAL POSITION OANY GO'VERITME;: TAL AGENCY
<br />responsible fox the leak. ?; e respcns_ble _nasty wound normal I be the tank
<br />owner. EFItLC"T_
<br />indicate awhi hon have been used to cleanup or remediate the 'Leak,
<br />SITE LOCATION Descriptions o_. ods -,.ons fo i_w.
<br />inter info.rmat;.on regarding the tank facility, At; a minimum, you most
<br />provide the facility name and 'full address. Ca d install horizontal imprr,maule ,layer t'La _..c.=e rainfall
<br />infiltration.
<br />IMPLEMENTING AGENCIES Cn t*t rr nt Bairrler -' install vertical dike to ,.docs horizontal of
<br />Entex- names -0f the .Decal agency and Regional state:: Quality Control Board contaminant.
<br />involved. Ex o avato aa,,, fi.>a�as _entivo ccr.tatr nated soil and dispose in approved
<br />sizc:
<br />SUL3,STANQZS INVIi,L li Eycavate ar,d Treat - remove contaminated soil and treat (includes spreading
<br />Enter the 'name and quantity ' lost of the hazardous substance invclvr-,d. Room or land farming),
<br />is provided for information on two substances if appropriate. If more than Remove Free product remove floating product fro-m water table.
<br />two substances leaked, list the two of most concern for. cleanup.Y „ .::a 1 c ..,;a ,rcztaz rlrz�t r - generally employed to ...,move dissolved
<br />contaminants.
<br />.
<br />DISCi117FPY ANATEMEhT EraY.a,.caid !,_ uc r<a „i;razz .isle of any available technology to phonate
<br />Provide information. regarding the discovery and abatement of theleak: bacterial .ecomiac„atl.cn of contaminants,
<br />R r ace S 1x provide alters ative water suppl.y to affected I az es.
<br />5C3lii2CF �° I ea menl a <sku- install water treatnictit devliceu at, each dwelling o
<br />dicate source, `< of le-,,<. `Check box(es) indicating cause of leak, other place of use.
<br />Vact«akx :E�z=..cG` - use pumps of blowers to draw air through soil.
<br />SEiYiE, Vent soi, - ,sore ?-role.== ire soil to allow volaat.za zat cn of contaminants,'
<br />zzdicate t%e case type category for this leak. Check one box only. Case tda Action apo"r r - into a<lezxE is ml toz , requiring no romedial action,
<br />type is ba::ed on rile most sensitive resource offeu.,ed. For example, if
<br />both soil and "gzound watery Have been affected, case tvpP will: be "Ground {C:?'E'NTS - Use this since to elaborateor.any aspects of the incident,
<br />Water". ndicate "Drinking rater" only if one or more'mtnxcx.,as or
<br />domestic water wells have actually been affected. A ;Ground Water" 3ICNA_U}RE - Sign ,.;e form in the space provided,
<br />designation
<br />tzcrs. not :upiy that .>?.�.w sffeci,Ed watcr cannot be, or is not,
<br />used for drinking water. but only tha
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