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PP__,,
<br /> INSTRUCTIONS
<br /> F14ERGENCY Lank iSeirx Ger f x cd' Leak suspected at site, but has not been con..;rmed.
<br /> Indicate Whether emergency: _sponse personnel and e u`pment were involved Prelim_nary Site Asje _,m¢:nt'Wa kr lar uubmt:ttu.i -:wnz plau,proposa
<br /> at any time. _f so, a Hazardous Mter_al. -incident Report should be filed requested of,/;submitted 'by, responsible party to detertaine whether ground
<br /> with the State Office of Emergency Services (02S) at 2500 Meadowview Road, water has been, or will be, impacted as a result of the mele<ass.
<br /> Sacramento,' CA 95832. .'Copies of the OES report fo-n may be obtained at Prel.iT nar-,� Site A sassaent ?,.dex;�r - implerrontat'on of s,ork
<br /> your local underground storage Lank aermit,ting agency.., Indicate whether olir,tz n C;l:aiacterizp. ,n responsible darty, is in the process of fully
<br /> etre OES xenon„ has been filed as of the ste of this renort, defining the extent, of contamination in soil and ground water and assessing
<br /> impacts on surface and' gro d ware
<br /> LOCAL AGENCY O' Y l inedia*_era Plan ear .iation plat submitted evatux ing long `sera:
<br /> To avoid duplicate notif„cation pursuant-to ilealtn and .Saf�tr ,code Section
<br /> remediation _ativn=, Proposal andm lets,.nt, ox schedule <�r <pk apr late
<br /> 251801 5, a government employee abould sign and Nave the fors in this:block: remediation, options al-so submitted.
<br /> A signature heave El ea not mean that the leak has beet, determined to pose aCl_a.i=.ti7 6 .h rwav zn,iesne<2tation cf.remediation plan.
<br /> significant threat, to human health or safety,- or,'_y that notification L2aLL—Clearlup 2lonit.or ri irz ? ogress - periodic ground hater or other
<br /> procedures have been followed 3f Tosca roan monitoring at site, as necessary, to verify sand/or evaluate e:`fe tiveness
<br /> of remedial activities,
<br /> REPORTED BY Case Classed - regional board and local agency in concurrence that,no
<br /> Enter;your name, tel.eptaone!ntanbelr, and address, Indicate which party you further work is necessary at the situ.
<br /> represent and provide company or agency name,
<br /> I:3PC)tt AN THE INFC,LNW.IO e s"32.^" DED ON a IS FORK, IS INTENDED FOR GENERAL
<br /> 5POYSTSIP lARCy S"ATISITCAL c',?RP{}SES Olk'i,Y At'D IS NOT TO BE CONSTRUED AS R,EPRESENTIN H
<br /> Enter-masse, telephone numrer, contact person, and addreas of ,nine party OFFICIAL POSITION OF ANY GO ERN `mT'A',. rGENCy
<br /> raspo:Bible for the leak:, ,The responsible party would,norinal.rly be the taro;.
<br /> owner R12MEDIAL, ACTION
<br /> Indicate which action have been used to cleanup ot. xelmediate the leap;.
<br /> SSTE TCICATTQP Descriptions o: options follow:
<br /> Enter .information regarding the tank facalitwy. At a mini urs,_you must
<br /> provide the facility 'name and full address. Cam Site iztstail harizonLal ir..pera,aeata;e layer to reduce rainfall
<br /> rn_sitration.
<br /> IMPLEMENTING AGENCIES CCont,ainmE:xt Barrier - install vertical dike to block horizontal mo eme:.t of
<br /> Enter names of the :local Agetxcy and Rsgional tate_ Quality Cont_cl Board contaminant:
<br /> involved, Excavate arta Dz, ¢s c> Tarsove „cntac_nate d soil and dispose in approved
<br /> S. site.
<br /> :aUBSANC INTN OLV. D f ca ate and Tr - remove 'contaminated soil and treat ,tr. ,.i,: spreidi.,
<br /> Enter the ,same arca c.earthy hast of the hazardous substance s; lived. Ronin or land farming}.
<br /> is provided for information On two substances if apprropriate, 1, more than Remove Free Product remove tloat.ing product from water ,able,
<br /> two substances leaked, list the two of :,cast concern for cleanup, namand Trt,:,ton:< ,_eL - generally employed to _e-:ova di..Fo--,.ed
<br /> o tam pant,;,
<br /> DISCGVFRYIA'3ATEM NT .1,.31
<br /> zlaa �c z.�a a a use
<br /> of�g �r�y _ _..W te..s.:oloS`s a ;.�r^.,aura
<br /> Provide _nfo.rat,on_regarding tfe,discovery.an ahare�._, „ f the __�Eik. bacteria decomTsosi" lo, ocontaminant,s,�
<br /> tL'L rs terinativ water supply to -ffec d rr
<br /> SOURCE/CAUSE w
<br /> at water t_':Oa,,�nent devices at Goc,. .d4ell li;g
<br /> Indicate 'Ouze..`,s, of leak. Checklrtxr,asl Iicating cause of eakc u nr ll<.v. v,.. �. __
<br /> ka u z r s pw r r blowers dr , ,
<br /> L na ?. l vola contaminants
<br /> a through soil,
<br /> t a �� � � za n of t� 2ar.
<br /> W1d_Eic!yttP.y`
<br /> the ase type category .rvr his leak. Check one box only. Case saw 3.� -c„i�.:r. es - a.. dcot is minor, re ,.ri,g no remedial c _on,
<br /> type a based r�az tfae most s�,.a e �,:�,.Tern � o �
<br /> both 50J I and o n i water <have been, afec:.e=, case type ai l; weG=;urd, sem” IS -- sT I ce to eiabo:ate on any aspects of the
<br /> Water", andic<ate r _al z t Water" anly if -one or more mu,n_,cz a^ or
<br /> domestic water wois ha7c,,e actually beer, affected. A "Ground Water" SIGNATURE the r,, t.;^ space }rv.: ,sl,
<br /> desigrsation doesrat ml'A;y t,l.a_ the :affected gate. cannot he, or is not,
<br /> ,,
<br /> used fordt_aux ra water
<br /> , butcrit' ,_n.. ,4 ,er we;.Ls save not H yep- F._-.a ?
<br /> affected, It is undo lstood that ,;a _ uype maX_, Dl:ange upon burthe— f t"as form irs__... by this tank own-or
<br /> aganetaz, t, e s
<br /> iIry es ti C I tl0n aMl6 f k__, the r.,, r intlect"to your rank nob beney
<br /> f e
<br /> ret cl . e n statuso, at `a category v , a , c Board, f
<br /> Che:k cease ,.,cs' ,r..y. Th, .e s ,....>,. z :,, s ia v to cav e, Un, as. t 1
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<br /> ,r<au.s:.r. a.,, rza„c. type J s Or .,n.� W_,,ne S Ft. e .._
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<br /> .... ground �;yw Y �_"., .Sr c_.�ac>� a,. �,z ,. .,.. { � £,_f.Uaa< �c,c,_
<br /> that of „.
<br /> f<Occ't., l5 .,. ., ",.k.,.. and, ...,.,..,.4x ,,..an-! wl#� 1 .,_.
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<br /> No Ac�'�oll Tall
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