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e inv"'i I v 'd
<br />wuh tm TV me 05 "o of 0- es a t 2-'- "'s so
<br />SmormonW, CX 91832. oi the WS r"mt form sin be oVanned at
<br />your iaca__ �_rJsrgvmod stmmo! 0WIR ye"voi-ting agony. 1WIC"s ehemer
<br />the OES reporL Las Ircm F�W an of Me date of this import,
<br />regann rA On dimovmv and abammuent of the leak
<br />Lmicatv sonnovQ) of 1"" Mmo Qx4s) indicatang catise of leM,
<br />"S
<br />Mosto We cme
<br />-sak, Check at aox only, Case
<br />Illk—ype isbased or Me ans; s="uoi,rte affected, For ezample, -f
<br />hoth .,...s and groinid wear hmn allected, case t, -pe wUI be"Wound
<br />Water-. Indicate -00nly af: one or more mornicipal or
<br />d,msstic water welis haw, w4uhn, b-�,,en affectod, A "G.rcund Water"
<br />design"Wri arms not ampo AaL W allmtM wnWr ca=rat be, or is novt,
<br />owed for dAn"Aq watms . bw mAy Mat watan weUK have nK yet been
<br />a ff e C' f rt r
<br />"od, It, is t�sat case type may change u�o ut tic
<br />investigat ion,
<br />anym
<br />ino icate the ca"('agory wh"' i, ! i'e'. " dasc ri tee, the CIrrento stat-sE o_ tn> cal"o
<br />Check one box only. Thqrwomwe .e,..
<br />.>u >...reizjtj,vp to we cme type, For
<br />exarriplo, af cas; tyy"e is -o"viod Water-, then -mirent Winn- QW11 leor
<br />to the st"us of the gmmd woure- or cle&nup, as opposed to
<br />that of sail, u taons'
<br />Rnhjomm TAya - No mt"r hm W,�-Pn tak�ui Isy re�,ponFihle PartY i�C-Yoa
<br />in'tt"i-al repai: t' Qf I �
<br />...... . . ... c snUearad a siLe. Em has raw been mkirmed.
<br />re
<br />respowelkly p=zv so deterinme whoWer grmndi
<br />W"Wr Los mm, so WKI va, mmmud as a r"At of We remass-
<br />S'- of w"ork-p an,
<br />-,i..!, Immy is in the process of fuUy
<br />d&jn�g the xrent of nmom"an,on " "il mid gromB water and amemog
<br />rmwNW.Wn. pAu vl4nwd emiusitimi; long tmm
<br />sched"'tle for appro'ir'�"to
<br />rMDA.I. ovums also SAMOA'_
<br />gjemEDajjdqrwqI� - imphowunation of immediation plan.
<br />PorIPAC ground water or cthe-_
<br />at zoo, as nemsi�azy� --a arc/or evaluate effectivensss
<br />"f:' h"sarn a
<br />reg"isn' a� d 1,,,_ ,emy i n conmrwrice then no,
<br />-,"is siLe,
<br />'PHE' INFDRYIATI N ENOWnU X TMS FORM W MTENMD FM CEMRWAL
<br />S T RROMS 0NIY An W NOT 10 BE CONIJUND AS FEMEUNTMO TE:,,,
<br />CF, ANY
<br />.. ... ....
<br />(>T A
<br />wilich action have b"n used to cleverap or rewdims the Walk
<br />Dcoic-"-ption", of opt"o'ns "i _ow;
<br />layi:r '-o rechice rainfa_'_:'
<br />"r -filtration,
<br />k to, bj.00j, of
<br />-,
<br />fv"�Wvt& and Di= romvo s',oil, ans, ispose in approved
<br />site,
<br />rcad
<br />s, Tr p in
<br />rmmw cmtminaWd suil and tr"t (Inc,Wdes 5
<br />or lmd fa-mmm"'),
<br />hm"% F"ejmUQ - "W"e fvmkin PlAwt fram Watar tably,
<br />hyn-0 T-wo 0—MAMVI - jone"A-Y i:e",,,oIeqea to remn-ve diss�,.)Ived
<br />contaiRnmos .
<br />-'u" ui'o of any '000"AL""I'le techno'logy to -fir_:,"')te
<br />bacterm! dqmwmvm. of
<br />-s w,J,,', supply to d -
<br />pr"As ahneris"m affecte part- s,
<br />pis
<br />w&v-c
<br />r at��.,.ent dioi
<br />evi,'s at: each dwalling or
<br />a t --ficos, insvaLL
<br />Ip
<br />ower Place of use,
<br />y1jImn Esvract - use lawo of blcwvi� to draw Or thininh swl_
<br />Vert 101 - bme holes in zml to 01ow volaUlzizathan of cmtmmaMs.
<br />ocident in v�_'_'ar? aoq�,iiri-ng no remiedial action,
<br />Use this space to el,aboo:ote on ary azpecta of the incident,
<br />LEagLj - Son the fGrm in 't -he spsr,-2, provi-dad.
<br />)J� JB(TITCIN
<br />A Me jorm , empletad by Me times cmer or hr,emt, retain the last copy
<br />d"'�d forward, t-ne remaini.'ng cci,re s -,,ntac� io, fgn,-io: loca! tank permitting egercy
<br />fer
<br />A. Cv"i,q - horal Tm* A,W-nnk Azmmi
<br />"a- ater (sw1o'y
<br />hmml HOW C)"Her WK Commy Moro, of sup,-' -visors oi, Meir designee
<br />ion
<br />
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