|
INSTRUCTIONS
<br /> Et-IIiGENCY ' _ - i �e�_AkIn :.onfi=med - Leak suspected zt site, but has not been cox firm d � '
<br /> indicate whether Pmergdhcy Y$spopsa pana¢nnel and equipment were involved, Fretffiina Site sessment oxknlan Submitted - workplaulP=op6sali
<br /> at any time. If so, p�Flaza dour [�aterra 14$dent Report should be fi14d' requested of/subm' ted by ;esponsib Le party to determine whether {,xound
<br /> wat as been,& will bq; impacted as a nesnit of the release
<br /> with the $tate Office of hltengenc�,.Serv'c s t4�S) at 2890 a obtained Road, _ ar
<br /> f �ies of e O apo i form y be obtained at _ preliminary Site Characterization
<br /> Underway implementation he process
<br /> Sacremeuto, CA 95832. G fit If jj - pollution Characterization - xesponsibie party is in the process of Sv11y_
<br /> your local un e= round'Storage tan permgtg. agency, Indicate whethei_ def- mg the extent of contamin t.en m soil and ground water ar� a'$ass gn,
<br /> the CES report has beta filed as of the(d►te of this Port. impacts on surface and/or ground water.
<br /> LOCAL AGENCY ONLY .`,1 .,Fly Rel tion Plan - remediation plan submitted evaluating long Darn /i. J)
<br /> 'ib avoid duplicate noryiflcation nrsuan �alth aml(`Safety code Section rerde ation options. Proposal and implementation schedule for appropr, .`
<br /> P $ ( ai remediation options also submitted.
<br /> 25180.5, a gov�annment`empioyee all si and date th� form in this br4. Clea tFb Underway - implementation of remediation plan. w/
<br /> A signature here does Mot mean th_- fie eakitras been der to pose �, Post Cleanu go,
<br /> in Pro x - periodic ground water offe'at;ther "1
<br /> sLgi,.£,.cant threat to hivaan health or sty,ronly that notification monlLoning at site, as necessar to veru} and/or eve.:uate e£fact ve-,ess.,.
<br /> p nc.dares have bdeA Seliowad f� ejj�.ecu-r '} /, �/" of remedial activities c
<br /> 1 ? '"C� s� ;i
<br /> / Case Closed - rv; nal board and local 99��envy in concurrence th no .�
<br /> REPORTED BY V - ♦ y).- / rther.work is neeassa;y at the $it 4
<br /> Enter you:' name, toL42ars, numb and :�te/s^: `'L:d4ate whiph partly Y. y ;
<br /> repr=sent and provide Fompany o�ayency MSme.T"
<br /> �' - IMPORTANT: THE INF TION PROVIDED ON THIS FORM IS AS REPED 1NT NC-5HA
<br /> A
<br /> (y C/' " / ' STATISTICAL P�1l�SES ONLY AND I5 NOT TO BE CONSTRUED S REPRrT.9fNTING S'HE�` q^,
<br /> kESYONSIBI.E, PARTY ;�
<br /> C FICIAL PC7SIT7.6N OF qNY GOVERNMENTAI. AGENCY
<br /> Enter name, Selephon2 umber, contact y +1�on, nd adf ors of the na;ty�_ '� i�
<br /> responsible for the .. The respon4SblE pa y wo�,1M normally be the // l
<br /> e RDIAL ?
<br /> owaex � � _ InPdd which whin actaob•if ave seen used to cleanup or remedia..e the 1oa6 f..
<br /> i Descriptions of options follow "
<br /> SITE LOCATION
<br /> Enter Information .g@;Qi ,g the:t .c,facility. At a minimum, yo.: must i '-� ✓
<br /> �}� Can Site instl�l horizontal n permeahle layer to r d.me rainfall ?/
<br /> prdvids ti,
<br /> facility s d�l4 eddr*dn. - T
<br /> infiltration.
<br /> Containment Barei67r - instal'.. ver*,icaidite to block hoxizq{ital 4soYement` f
<br /> 11,
<br /> Entnames—er o- S the 16131 agency �rfid Reg-ona lex Quality Control Board Excavate and Di s se remove contaminated soil and dispose in. pYroved F'
<br /> involved. s'.te. �
<br /> }}�� Fecavate d Treat ren' e con un_aated so'.1 and treat (3i�cl�des spree
<br /> SUBSTANCES INRObf'ED _ /- o- -and s min )
<br /> Enter the name end giy§lt,ity Ps f ,Fie� us substance involved. R6om g w F't
<br /> is provided o inford)ytioh o L s SLaec�f appropriate. If andr an Remove Free Product mo e floating nmd:ct Isom water t�ble.
<br /> rgro subtle_ eyke�A.111 a o. L ncdrn for cleanup. .. `� W n `d Trea Groundw te. - gene ally amp eyed to remove disco
<br /> n contaminants
<br /> 'l7 "4Y fy 1
<br /> -�' ,.y- 1144// Enhanced 3ioaegTadetiov :.:eaE any ivail<h1e technology.tq pr w
<br /> DISCOVERY AB ENT i��� moi,- //�} II bac eYial dec,mro ,.tion pf cantaminax
<br /> Provide infer ion p#ard�ag the ditcovary and abatement of the leak('. Re ce 5 1 piov-fie alternative water supply to affe%�d p
<br /> �OIIRCE/CAUSE / Tr cent at Hooeu r-nsLall-water treatment devices at each
<br /> o er Pia ejof ass` YYY 1
<br /> Indicate source(s)=of Check box(6s) indicating cause of leak. -+ Vac_um nx a t /use Pumps or blowers to draw air through boi'_ .� v
<br /> lJ Vent ' of holes in soil to allow volatilizatlon a$ obntam_nants.
<br /> ASE TYPE .S^ N A a: -d -no,.dent is e.,inor, r quix.ng ::o re0u�ia1 act�0�
<br /> Irdicate'tht,cise't a ataa���'y fox oh oak. check one box only. If/, ...
<br /> type is based qh th at allfsit ve se ce affec Sed. For example, iffy
<br /> both soil and:roun er hay en of ted, case type will be "Ground- CO"S.Eh S`�d: Use this w{pace to elal:orate on any aspects of the incidpat.Cr.
<br /> Water". IndiClite at only one or more municipal or �- _ 1
<br /> domestic watezjwell e actU been affpe$.ed. A "Ground Water SIG64 UFF�� `i gn therm in the apace provided.
<br /> df y (%
<br /> designatipn s no ly that yCfe affect ater owner be, or is.not, DISTRIA:r, ON 1.
<br /> uu¢¢$d forzlr nk yynng wet��tP but dnWthat Ovate ells have not yet been --�--. r
<br /> af�eoted. Zi le under�.Pod th saw type 6" change upon further if the form 1, comglaWd by the tank owner or his agent retain the -asi�
<br /> muerte atipn. , �[ and forwaW t e redia' ng copies intact to your local tank permittimt, again
<br /> g for dist;i&t on. I11 - r
<br /> CfiRRENT ST T S Oi Lina Local :.k Fenoitti:g Agencv _ I
<br /> It T tejorip
<br /> ich bast destri¢¢es the c4=tent status of the case, 2 Stat,.W r ReSoyzc s Control hoard, Division of Clean Water Flog s,
<br /> / _ ¢cld Pass bbx4only. xaspon shou17"be relative to the case tyte. For Re i4 1L2:e0� .t nd Cougi r Pi O. Pox 44712, Sacs amento,rfA 9j(244
<br /> Zn2yro..`j St ank Pro
<br /> t/ e Ple,`if kgse typ "Gxou ater"�th "Current Status" should refer
<br /> tq the sfatutLQt theand coat investkvE j or cleanup, as opposed to 'Q4 i Y o1 oa,d /
<br /> that of soil i Descrons Pf p ions 11ty fi i -'e Board of Su .,r' l;ors nr their]JEs _
<br /> h i u - '(''"/'/ ,I�roposlti notific at..ons. ,1
<br /> .� No Actio�Seksn action {'f9s bee�az�{ by responsible partylbeyonqe artyLniti alir yon . nak. „i Q 4�✓ �° i�'
<br /> L
<br /> go
<br /> Aj
<br /> L
<br />
|