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EMERGENCY beak Beira Conf'i,rmcd'- Lack suspected at .si c, but has not beer;, confiiino>d,
<br /> Ind cafe wi:ether emergency response personnel and equilssent waea.o involved orkrian Submitted - workplan/propot>a:
<br /> at any time, If so, a ;Iazarcicrss Material.. 'Incident R6port should be ailed
<br /> requested of/submitted by responsible party to determine weather ground
<br /> with the State Office of Eszcag,ency services (OES) at 28DO Meidowvien Road, water has been, or will be, imoacted as a result of the rel ase<
<br /> Sacramento, CA 95332, � <
<br /> Conies of ttOl report, foxsn may be obtained at P rsrirnar Site Fs,a :Hent inderw<av imp7esrenta"on of workplan.
<br /> your local underground sto-rage,tank permitting agency, indicate titteri1.1ut on Characterization - re is al..e lz...t n the process of folly
<br /> the OFS reror he,,: re_i. ailed as of the da,o of-this report_ defining the extent of coo:tamination n o , .ad _ound water an assessing
<br /> LOCAL AGENCY O _v � - n ..
<br /> Macts an s arfacc ; Ica gen I a
<br /> i_, mea.::a on :'l. r _se _utiou plan suIlmitt,d evaluating long
<br /> To avoid duplicate notification puzsuart, to Health and Safe y c de,;Sectlon res:edsation options. Proposal and n...d sat,a'tian � Izc hAe fog apr�.o„riate
<br /> 2M18s.?.5, ;a government employee should sign and date the fo-4 in this bloc, remediation rept-ions alscs smbeditted,
<br /> A nigra .are here does nut mean tna., the leaf has been determined to Dose a Cleaiici C aderwiav - anodes esztati.cn of r edict cn pp.axr.
<br /> s1.g<zi carat meat to I ,grai3 t,caLt`ta or f'c;y, or. y that;"r>oti£icati n Fast Cl azzta 'a9czxa.torix in y,=res - periodic groan i water or. v_.^er
<br /> s
<br /> procedures have been followed if roci{tires, monitoring at site, as necessary, to verify and/or evaluate effect.rVeness
<br /> a
<br /> of remedial, activities.
<br /> REPORTED BY r p Case Closed - regional onal board and Soca: agency in concurrence ,ha 1-40
<br /> Enter your name, telephone n.rsbe:• and addeszIndicate which panty you rthar work is necessary at the si'te< ,
<br /> present and, provide company or agency name,
<br /> SPO AN THE INFORMATION PROVIDED ON THIS POEM IS INTENDED FOR GT'NTER5h-:
<br /> ESPCNS7saZE PARTY SinTIS Tap,.L _uRPCJ 1 S ONLY r1tuO fc +... (� a
<br /> S NOT TO E CONSTRUED AS R,%x�`'rRE`;EI�TINQ,,Tin '
<br /> Enter name., telephone number, contact person, and address sof the party OFKCIAL POSIP ON ra,
<br /> �.� ANY 'GOVP.t1R'tE?,TA1.. ACLN..1
<br /> responsible for the _eek, The responsible party would nQrzrally be the tank
<br /> owner. R}::I.1EDIAL ACTIO
<br /> Indicate whack action have been used to cleanup; or remediate .he ak„
<br /> SITES LOCATION Descriptions of options follow:
<br /> a nter inforriat .firs regarding the tank facility, At a minimum, youmust
<br /> provide the facility name and full address. Ga�i�e - inz5tall horizontal imper oablc'layer to reduce rainfall,
<br /> i.'_i.'tration.
<br /> IMPLEMENTING AGENCIES containment Perrier _nstaTi vertical dile to block toriuontal'nove;rent of
<br /> Enter names of the local agency and :eg'on _ wa'teµ Quality Contvrol Board contain rant.
<br /> involved. " zc-agate <duci fz s)case remove contem nated stem and dispose in apprcxed
<br /> site,
<br /> ' S 1
<br /> SUBSTA:tEMI. ,i) r.acavate and Treat - :eanoLe contaminated soil and treat (imc!,.de, spread'.:�
<br /> Enter the name and )q.ran'tit;y Lust, of the haz<ardaus substance, taaulved• Room or 1 a-,cc farazing).
<br /> is provided for in ffcrrslatior on t,,wro substances if appropriate, if a„ore-than Remove Free Product remove float ng product from wste, 'bje. .
<br /> two substancez leaked,rsd, list tlza two of m,:s'yt c� ole mn- .met czwaetn1gene-<:ally employed to remove d ,. o]_,,e=d
<br /> DTS (VERs IR 17 MFN al�race 1 :>ro�)sc d,pi,cs=a - zsc�_of at.y
<br /> �_ pal>; to t l; a prc�..s ,;e
<br /> Provide _raw „..... Act. re diz.�, the p s ovexy and aka€ to ,at of the l._cak. acterial decomposition of contaer. ria,.:d,
<br /> L acme- pvays al,ers ative water supply f . affect ed p.a
<br /> SOt < E,/ Pt c e - aiL water e<a en .1 •>Sce a each �d 2 ..� or
<br /> ins-
<br /> Indicate zouzoe(a) of leak, Check box(es) jpndicatmg crause of lea_ . otlhcr place of use,
<br /> "r a m Ex
<br /> WESE TYPE t u = poop or blowers, o draw air through soil.
<br /> bore rzJon
<br /> of s ontar na2ta,
<br /> Ziaizcat,e the case type ertegoa.y l..r this 1,a Cr.eck one box only. C<._ ?#cx ActionI Requjred - ac,r.:.dexxt is nor, .e ring no mama:., a1 acts tt,
<br /> type i, based Oil tine most_sensit,,ve, resource affee-ed• Forexample, if
<br /> bath so-,I. and ground water have lDien affected, ease type ill. be Cr:ouz.d C *114 NTS - Use this space to -elaborate az. any aspects of the ncs :eiat:
<br /> -c
<br /> Water”. s.<a:ti,r;ate ,',,r .tka.xzp Water" on<.y if o<c� or .more m€�rsczs}as or
<br /> domestic water wells have actually been affected. A "Ground 'nater" SIGNATURE - Sign the form in the spare provided,
<br /> designation does not s, ,.y that the affected waver cannot be, or is not.,
<br /> used for drinking water, but cn y rhat water wells have not yet been DISTRIBUTION
<br /> affected, it ;s understood that case type may change upon further :f f,lze. arm is completed by the ureic owner or .<is assort:., >e,a_.s .,.:e-1-ast copy
<br /> serest:s at'_un. enact forward the reznainingl copses, intact_to your soca?. tank pteniuttiSag agency
<br /> rcr .>txib!,�ioza.
<br /> CtRREN'r 1 ('ii 1. Oxgina; - ::coal Tank xermJtt,ing Fger.r
<br /> Sn 1 �a*e fzs r_t,�l y m?tink bez" <.r_a to cu rent status of the cs.ac. 2. to v a. Tensely oes`ucTrtro7_ �c«rd; Jx.� �inr< of C'
<br /> .eau. <xicl � .cs. <rs°
<br /> Check one . ox only, The =es,o s.e should be r.ellative to the ease type, dear Ub,de. grotnd Sturage Wank Prograa > r„0. ,. v 44 212, 9 1244-
<br /> r<a:kp.I.< if c .. type is rca_.cuv Staar,.< should
<br /> ccr 211.12
<br /> o the of 111he vraund ra.tt.,r :iz jes,'Gnr; _,sn of c7 ea n.p. as opposed :.o_ 3. Regj cna< Water Quality Co_.tro ?ao a-rd
<br /> that y
<br /> oz scr9_t, oris r o n. k�;... �r: L c He ul_ 0ffi .cr Td C0'nn t, „cai_? c,F .soap eo,-s . t.hel do-s e to
<br /> _
<br /> rkLz�s . _ .,, �.c. , tc..h..c_.r,.
<br /> Na F _ a? x.,_ - No cL',,. t t,...:r b e,sro4siblo ;iso t r�eYun. 7. 2_z�:.e.a #,L_ party,
<br />
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