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SFISllucI IONS
<br /> r_MI,RGEt"Y CURRENT STATUS
<br /> fodir.ai whetrc, ^nerceoGy *.sponse 4rsonnel and e.,N p ert-were five:.ved,at 'heik on tbo category he h post de c rhes the cu nt status of typ .icer
<br /> any time. ff sn#a Hazardous Material Incident Report shopid be filed with example,
<br /> one box only. The response should oe relatrre t the type. F r
<br /> s
<br /> the State CffE r cf Emerggenvy Services (DES) at 2 eado iew Road, example, s case type is water
<br /> '.last r then currant Statu Opposed
<br /> ti � to
<br /> SacrarlensoI CA ' 832. fopie;>of the BES report fo may h obtained at your the status of the ground water invcs,d ga Lien or cleanup, as opposed to +rat of
<br /> local stili rgr., a storage takiik permitting agency. Adi<arwhether the DES scut.
<br /> repot has been ilei as of..the date of this report ',Y MMRTANT THE iNFORMAT ON PROVIDED ON ti:S FORM S -.-.NT@NDEI FOR E;E2A-
<br /> IA('nL AGENCY'@J Y !`i SiATIST;CAL PURPOSES DV Y AND IS NOT O B_ CDNSTRu_.. AS REPlckNuNG Th`
<br /> '�}allo� i ca to,no ati _ ursuant to health and Sdf Cod Section JFF I+ lAL 'CSIs i-r`! OF urY „r1E4 d+;EN1 r A FN.:Y
<br /> # 8d.3 a designa(ed rn employee should si*. and to the lo,.T in REMEDIAL ACTSON
<br /> �thi bTock.p A srgflaf g,, etc es rpt 6rean that the leak been h e mined T—ligate who-'actions 'ave been usad to cleanup or remcei4ti, ,he lea,.
<br /> to d„ise a Siam t,cant tG5`gat umawlealth or safety, only that-Aotjficatior. Descriptions of optdr,s follow:
<br /> irocedurbs fail. UPen fp w d recptiral , ,-t
<br /> v'3 f D�app��S� r to ins to! her; ortai �mpermeab:e layer t recuc ran ;
<br /> REPORTED By. i )) infiltraro
<br /> Cntar your name, telephone nu r, an ,raw. . Indilate #jich palftg slaw Containment Barrier install ve*tical dike to bleck hon ontll mcvemeat
<br /> rep went and prov(de company or ageACk raw. -d'� _ o, contT anrnan,-
<br /> d ., �_,` Excavate and DiSDnSo remove o -aminated soil rid allspcse in appro:rad
<br /> RES?pNSIBLG PARTY a
<br /> ni r name; te7t+ph nr nuitbe contact pC�rsottya and ad ess 'of The party Excavate and Trea^ r mov- contamrmted son ar. treat rn,i.;des
<br /> E *Pdn5ih}e-for thi teak,.,. ha respaMEfDTe pjrty would nornral7y ba the funk spreading or;rid arm ng'.
<br /> cwrn<.{. 4C l�iyi `. l Ra^�c_ Free Pr_L rcreve et - ., —OAu t F. waren
<br /> t Rable .
<br /> SITE OCA'L:ON ! (� Pv and ra t (coon dwater - generally employed to r-move dissolved
<br /> Ea r'In rmat ion rega�img the tank fabilipw and surrounding area. At a m an --
<br /> minimum, you must Prov sheacility a�me'aod. full address. contaman3n S
<br /> ff, Enhanced Biedr_gngdation - use c. any available ternnology t9P rodroto
<br /> itdP Eni'lA iNG;A6GR�irS /I 7 bacteria—dee tion of contaminants.
<br /> Ent r nares orf kPe�QcSy ge tr' Replace Su i - r vide alternative water Supply to affected i
<br /> a n and Reg(�ai 4ater 2omltty Control board -P�� p 4 Pp y
<br /> involved ! +J. _. _ parties �(�
<br /> r4 -reatient a Hook:n_ install water treatment devices at each hPfg7li ng or
<br /> SU STANCES INYoum" , ^"� " gthor Place use ,
<br /> C:rT rthm rime And_flOAn t4 ty l'6t of� haza�9ous s Cance invoiyad. Room is
<br /> No Action Required incident is minor, requiring no
<br /> provided fop it rrmation on twp)suhs,�anoes iY-appr 'ate_ If xp4re than two
<br /> remedial actron�
<br /> sub e r r eak d list the two of most concetn for. reanoo.
<br /> B ,.i COMMEti, Use this space to elaborate on any aspects of the incident.
<br /> !d OISd DvrRYIADATEMENT �^^yfy� ij; r , S ATTIRE Sign the form in the space provided.
<br /> vrc ode mfr*:radion rag6rding e dtoyery�d atia'Tpment of the,l�eak. 03UTIDN
<br /> L
<br /> SOU C rA'�SE 71 If the farm is :repleted 6y the tank owner or his agent, too las copy
<br /> Cnnicer¢ Som cels) of leak'. Plereide Wtaiis on tank age; capacity and. and forward the remaining copies in tact to your local ranknk perper mitting agency
<br /> for distribution.
<br /> maternal if knovfn. Check hoxie 1 indicating cause of, leak.
<br /> r.S' 1. Original - Local Tank Permitting Agency
<br /> CAS' _Y PE i�) 2. State Water Resources Control Hoard, Oivision of Water Duality,
<br /> ri a+e the cage type categeryxfor this leak. CheNd one box only. Case type Underground Tank, program, P_ 0. Box 100, Sacramento, f gSBCi
<br /> is bas<d on the "ost sensitive source affec"ed. For example, if both soil 3. Regional Water Quality Control Board
<br /> and ground water�ha, been aff ted, case type will -kk "Ground Water". 8• County Board of Supervisors or designto receive proposb5
<br /> 'rtl
<br /> 'Drinking Bator" oN if one nr moi{ muni cr,,�,al or domestic water 0 notifications.
<br /> g y'•. "I 5. Owner/responsible party. ,
<br /> we is have actually been affec d. x ' rou(� 'Water,{den gnation does rot
<br /> inp , that the affected water pnnot b yE or is not w=_od for drinking meter,
<br /> out ally rnat.a/ajer wells have not yeken�ffected :t is understood.that y '7
<br /> case typo may,6ange upon further investiga
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