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I NS T=RUCT H.)KS
<br />MERt:E111CY
<br />dT.tr� whctl",er emergency response personnel and eguipm;:nt were involved at
<br />1.i;V t'i(�, If sg, a H;azardg:fs Material 1nezide!€t Report should be fllcd with
<br />the Stag Office of Fm rgency Services `OESl dt 2800 Meviowview `Rad,
<br />Sacramento, CA 95332. Copies of the CES report fors?€nay be obtained at ,your
<br />local unci*rground storage tank permitting agency. Indicate whether the CES
<br />report has tyr=es filed as of the date of this report..
<br />LOCAL AGENCY ONLY
<br />To =<€ l ca e notification pursuant to Health and Safety Code Section
<br />75?$ a flesicnlated government employee should sign and gate the form in
<br />this hiilck. A Sign€art}r<' here d 25 not mean that the leak has been f{fr'ter'i;,iried
<br />to pose ') si Gni fic ant threat to }film! -in !Seal th or ski fety, .,On ly tha: noti f'ication
<br />prctfdureS nave keen filllowed if reouire (J.
<br />REPORTED BY
<br />+±t.er yoE,r narm, t(lephone number, and address. Indicate which party you
<br />represent and provide company .or agency name.
<br />RESPONSIBLE PARTY
<br />Enter^a1u, t=lTpEhone nu..tiber, contact; person, and addr'e�s Of the Parts
<br />responsible for the leak. The responsible party would nonrially he the tank
<br />owner.
<br />SIT`: t :ATltil
<br />In*= nlcrrnation regarding the tank facility and surrounding area. At a
<br />minimum, .you must provide the facility} name and full address,
<br />1I4PLEN1, NTING AGENCIES
<br />:.nt r na€ ss e t`.he t sial agency and Regional Water ;=ual ;t; Control Hoard
<br />involved.
<br />SUBSTANCES .INVOLVED
<br />I,aer th!; name erg 9liantity lost of the hazardous substance involved. Room is
<br />provides for information on two substances if appropriate. If more than, two
<br />s€;bstinces leaked, list the two of must concern for, cleanup.
<br />0ISCJVERYr'r1i3Ai£]ME17T
<br />1}revtcie r.f tr€€iatpn regarding the discovery and i?b,ate.ment of tl'sfleak.
<br />SOUR(:E/CqSE.
<br />TMndl a r"s urce;.si of leek. provide details on tank age; capacity and
<br />.material if known. Check box(es) indicating cause of leak.
<br />CASE TYPE
<br />5iTi*CifTthe case type category for this leak. Check one box only. Case type
<br />is teased on the most sensitive resource affected. For example, if hath, soil
<br />and `fr•ojne; witer have been affected, case type will be "Ground Water",
<br />ln(H cazte "Drinking !rater" only if ons or more ,municipal or domestic water
<br />wells :have actually been affected. A "Ground Water" designation does not
<br />,that the affected water cannot be, or i5 not; used for drinking water,
<br />bur. Only that water wells have net yet been affected. It is understood that
<br />case type may charge upon further investigation.
<br />CURRENT SIAIUS
<br />;rids tl.e
<br />.y which best describes the current status of the case.
<br />Check one box only. The response should ae relative to the case type. For
<br />exampl^, if case type is "Around Water", then "Current S'atus` should refer to
<br />the status of then ground water inveStigat?on or cleanup, as opposed to that of
<br />soil..
<br />I;fii%Qk-ANT: THE INFORMATION PROVIDED ON THIS FORM IS 1NII.Pil';€ED FOP G --NERAL
<br />STATISTICAL PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REPPESENTm'; THE
<br />(1FFICIAL PQSIT7'ON OiF ANY GOVERNMENTAL AGENCY
<br />REMS.)IAL ACrioN
<br />L WhRa actions have been used to cleanup or remediate the leak.
<br />Uescriplions of options follow:
<br />Can Site - install horizontal impermeable. layer to reduce rainfall
<br />Tq T 31 *i a+ yr
<br />Gortalr nt Barrie r install vertical dike to black horizontal movemFnt
<br />Excavate and Dispose - reiix)ve contaminate=d soil and dispose in approved
<br />Sr te.
<br />.Excavate and,.. Treat .- remove contaminated soil and. 'Creep (includer,
<br />si}rc<ad—in g dr TindFfarx!ir€g),
<br />Rei;ove 'Pref Product - remove floating product fro+r: water
<br />fel L3 €<_..__._......_ . ___—
<br />Pump and Treat Groifrdw,ater - generally employed to remove dissolved
<br />Ci3,ita€Pi!iant5.
<br />Enhanced Biodegradation - use of arty available technology to promote
<br />a;tr>rieTcTec�mosltliii of contaminants.
<br />RePlace. Supply - provide alternative water supply to affected
<br />i3articS.
<br />Treatment at Hookup - install water treatment devices at each Awe! ling+ -or
<br />No Action R=.,.,,fired incident is minor, requiring no
<br />rei.ila1 ai;+rrn.
<br />CI)M*'NTS - Use this space to elaborate on any aspects of the incident.
<br />Tu'.L
<br />4MIA— R - Sign *hf? Corm an the $para- provided.
<br />UTI TIRIffl I o N.
<br />If the form is completed oy the tank owner or his agent, retain the last copy
<br />and forward the remaining copies in tact to your Local tank permittincg agency
<br />for d1stri6utIn,,n.
<br />I. Original - Local Tank Permitting Agr.•ncy
<br />2. State Water Resources Control Chard, Division of `'tater Quality,
<br />Underground Tani( Program, P. 0. Box I4C, Sacramento, CA 95861
<br />? Regional Crater Quality Control Board
<br />4. County goare of Supervisors or designee to receive proposition 65
<br />not! l'i ^o titins.
<br />a. iiwne.r/responsible party.
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