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INSTRUCT IONS
<br /> EMERGENCY L ak Beist� Corit'i imcd - Leak suspected at site, but has not. been 'confirmed,
<br /> Indicate, whether emergency response personnel and equipment were Pre?sm n r pit_ Az,se�esm:nt Wozkotan Submitted - wa kplan/p, posal
<br /> wt,.alay'time, IP so a fiaza.rdcus Materzal'inciden Report should be ¢gibed requested of/submittedy responsible party to determine'whethe::' ground:
<br /> with the State Office of inargency Services ,OES3 a:. 2800 Meadow isw Read, 'r water has been, or will be, imaacted as as result of the sel.eaae
<br /> Sacramento, CA 95832'
<br /> Copies of the c:LS report form may be obtained a at P e z.ni aary Site Assess, en ':der:kay - implementation a work-
<br /> your lace' underground storage tank permitting agency. Indicate whether Pollution Charactexiza,_onres;�onsiale paxt,y rn `?:e Process of fully
<br /> r
<br /> `the OF,h epo;^'t has be ,'t fled as of the date of this report, defining the extent of .,.��nzxrxr�to of
<br /> .,�s xo.i 2rT soil x..ai gwc zs:,, water and assessing
<br /> La a is at, dread and/or ground date
<br /> LOCAL AGENC'1 ONLY z media en _lar res; d.ation plan s r�rit teed evaluating long ter_
<br /> 3'o avoid uprl.ivate natificataon pea cant to F'ea`t:: and Safety.- cc e Seetiaia remediation on ions, P:oposrl and ;.nuleraFnte icfa e:zcu;.?.e _ pp ria`.r
<br /> 25180.5, a government cmvioyee should sign and date the 'Ozn, in this:block, remediation options a „rr submitted.
<br /> A signature here dr?es hot mean that the Leak has Leen deter linea tc pose a C;.eanu�,U-nderwav - 3rpl, t,cyit tic s of remediation plana"
<br /> siplif.+dcart threat to human health or safe v, onl tha notifi=cation Pas u�eautiz nitor: an Pr<, cess periodic g.ra d rater or other
<br /> }raced are.=> have }}ooze followed if required. tra.�r a, s..g at site, as _eccssary, uo ve i4`Y and/or evaluate effectiveness
<br /> of remedial activities,
<br /> REPORTED BY ase Ci se i regional ward-and :.ce L agency i r n, rr�nce that no
<br /> �neer ;you name, tele b ne number, and address, indicate which party you further work is necessary at ter site.
<br /> aaresen� ax Provide s ,any c r agency name,
<br /> !11FORTANT: THE INFQI�'IAT!11114 PROVIDED ON THIS Fa&Nj IS INTENDED FOR GENERAL
<br /> RE7PCN5T131,11 PAf't`Y
<br /> STATISTICAL PURPOSES ONLY AND IS NOT TO BE CONSTRITED AS REPRESENTING __E
<br /> Enter name, telephone n.m ar, contact person, and address of the .ar", u_T iClfi� POSITION e ANY GOVERNMENTALAGENCY
<br /> `
<br /> responsible for the .1 -The responsible party would norc:_l`�t b. the tank
<br /> owner. REMEDIAL ACTION
<br /> in.l}.cate which action o have been en used to cleanup or remediate the leak.
<br /> SITE LOCATIOND Cariptions of outsons folacvr_
<br /> Eatcx in£nrgaafion regaling the tank facility, t a ainir.w , 'yo.e must '
<br /> provide the facility name and full address. Can Site'- install i. horizo ntal. impar cable layer to reduce rainfall
<br /> Tin t,rataon
<br /> IMPLEMENTING AGENCIES -Containment Barrie: - 1.3tall vertical, dike to block horizontal mov mens, of:
<br /> Entex names of the local agency, and Region-_ TWate�: Quabity Cortrol Board contaminant.
<br /> involved. r _ ,
<br /> Excavate arae .a::. rosy " _ "move cont niated ;oil and dispose isx approved
<br /> site,
<br /> SUBSTANCES ZNatlV l
<br /> i Treat - „ : fxcavate , oanrea ( rc_ eo �pxe,an_M:g
<br /> Enter Lha name arxd cr;a ntaty lost of the hazardous substance involved„ Roomas land fanmingl.
<br /> is provided for information on two substances ff<appropsiate, If mors '.ham Remove Free Product ):omovo floating product from wa',er ta<,1...
<br /> two substances leaked, list the two of most- caraeernz for cleanup:: Pump and Treat Graundwaater - generally employed to removedis so,ved
<br /> contaminants,
<br /> LISCOVERYlABATEME2>T EnhAnced B_ ?ea: a i +n,za - case of any available tec�aatol.ogy to promote,
<br /> Provide infozm.ation;x ga din the d:scover� and abat,en_ut of tlxs Leak: bacteria' decromposarac;n of rcontaminaiats,
<br /> R ace: T prOvic alternative waters supply to affected par ,
<br /> SCURCE/CA05E ' ea inert a Hookuo -`install pater troatment devices at each dwelling or
<br /> dicat'e sae-loe:s? of leak; Check box(es) indicating cause, of leak, ether Place d» e
<br /> V-m m Extract use ps or blowers to draw air throngh soil.
<br /> u,SE SYPT: Vent uoi_ re holes in SO4 1, ro al?ow ra:<ii,.4 zaw on of`contam_.nar„�
<br /> �
<br /> Indicate the ea '2 type ceatega y 4TH this leak, Check ince boy: only. as N �z.tien ieefri're - sx,.;deax.. is miaor, r:equirin o remed_a1 ..,c:;;r n,
<br /> type is based teal the'io.st ;".nsit.,ae we_c,:rce af`ee..ed. Por e7ample, :
<br /> both sail and ground ;darn e.r have been affected, case tye will be vinic? r E 'S - Use this space'to ei.abea-sate on any aspects of the i*ac dent.
<br /> Water" rid.i.cate ,Lsx<,king Water" only If one or =-_s mn. .zs,a- or
<br /> a0m, estic coater Wells ?-Rare actually bear affected, G•_hu_d i ate " SIGNATURE - Sign rra'In .dace provided:
<br /> designation dills rot its„v th rfected water cannot be, o], is n o:
<br /> use( for drinking, rt t we z r yet mss, O �t N
<br /> afPe t 'd< it it n..,.a w, a aM, type may .a.,g_ on further F e €,rr� z r c„� D� i - n:e._ .: s<. a n a y
<br /> ax es a atir n� r .1 i
<br /> the na x ._..,p-c.,. w iii <; t to �r>,xr: c..a tank r, n.•;r
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<br /> ate the c<i��wzx f whli c€_ best le-cr_best the current `<t;atu_ Of _.< .__ t'a„W_ R�- of c. ,v_ Board, r a t of
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<br /> t ly” e ?, e < . u the a pin,,._ei.. >`ao 0. Tw _r ?_ 3.. TP,C. x? )44212,
<br /> t m is ae pe t � zre” r
<br /> r1to the st,'�tus of <' r> .1 water, E.. C .,I`Ltk S t e,r Q t y c. fix. Board
<br /> W17,a :5t.„. C. _ .i-,n of ,...,I.. to =ow: feet .,4, _,_. .,,'(1 CS” and L, nt Boar'?:k
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