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EM"eRGENCY NSTROfI IONS
<br /> CURRENT STATUS
<br /> ndi amp w h r -a rgency response - vsannel and -.qui.hoot were invpi ved at Tnm Let -tie category which best describes the current status of the case.
<br /> a ince. [I so a Hazardous Material In idem R port should be. filed with Check one box only. The response should Se rel
<br /> * e Ste , Ofri e of Emergency Sery es (OES) at 2800 Moalowr'ew Road, p tative to the case type. For
<br /> Sa r mento ,A. 95832 Copies of the ORS report form may be outahned at your examotatusfocase type
<br /> he ad `Grounwater d Water",investigation "Current
<br /> nuf,Stas opposed refill-
<br /> of
<br /> .10_:31 tall"-round stcrago tank permitting.agency. Indicate whether +he 0E< toll.
<br /> report has been filed as If the date of this report.
<br /> LOCAL AGE_WCY 1.-NLY. IMPORTANT: THE INFORMATION PROVIDED 6N THIS FORM IS INTENDED FOP, GENERAL
<br /> io evgVo dii�3ica to notifica ti p y 5TATISTICAL PURPOSES ONLY AND rS.NCT TO 6E CONSTRUED AS ?EPRESENT INC, THE
<br /> pn ursaant, to Health and Safety Code .Section OFFICIAL POSITION OF ANY GOVERNMIEC, A AGENCY �
<br /> 2518n.7, aesio ated Tove nment plop i nyit.should sign and date the °arm in
<br /> this s' ck A s tor ht doe not Alta the' the leak has been det .wined REMEDIAL ACTION
<br /> to, pgs+. a significant rh ra *o hamar health or safety, oriy that notification ar3i ate whicfi—actions have been used to cleanupor remediate the leak.
<br /> p crni.res have U.eg followed if rear red. Desch poi ens of-actions
<br /> follow:
<br /> REPOVED BY
<br /> arty you m
<br /> name, telephone number, and address. Ir+dicatp which P Cap Si - irstali horizontal impermeable layer to reduce rainfall
<br />• your
<br /> represent and provide company or agency name, tdfiltiaticronta nment Barrier - install vertical dike to block horiionta'i movement
<br /> RESPDNS113LE PARTY of r(T*.aro hanL—
<br /> anter r:a,*e,te;ephgne number, Contact Person, and address of the party Excavate and Df spose - remove contaminated soil and dispose in approved
<br /> E responsible for the leak. The responsible party would normally be the tank Excavate and creat - remove contaminated soil and treat owner. - at iincludes
<br /> soread nng or land—farming).
<br /> SITE LOCATION Remove Free Product - remve floating product from water
<br /> En, :r+rTcrmaticn regarding the tank facility and surrounding area. a tuT
<br /> mhrimm, - At a Pump line Treat Grounrzip
<br /> dwa*p - o>nerally employed to remove dissolved
<br /> You most provide the fan 11 y name and full address. centaall _;iant9.
<br /> I117LE. de
<br /> MENTING AGENCIES Enhanced Biodegradation - use of any available technology to promite
<br /> dterla SS[t Oti of contaminants,
<br /> dc5nn ii
<br /> Enter_ dmes o€-[fie Tjcal agency and Regional Nater Quali;y Control Bpd rd bc
<br /> Replace Supply - Provide alternative water supply to affected
<br /> Blueed.
<br /> parties.
<br /> SUBSTANCES INVOL VIC Treatment at Hood - install water treatment devices at each dwelling or
<br /> rrt r tnr name ina-nuan tot lest of the h other—PT--c e chase.
<br /> y azardaos sobstarce involved, Roam is No Action Riauired - incident is minor, requiring no
<br /> urovidec for hr Formation on two substances if appropriate. If more than two reTedis9action.
<br /> substances leaked, list the two of most concernfor cleanup.
<br /> SCOVERY/ABA+EtIENT COMMENTS- Use this space to elaborate on any aspects of the incident.
<br /> SfGTJA-Y`TRii E_ - Sign the form in the space provided.
<br /> P rc�i ie nformaiioh regarding the Aiscovery and abatement tainent of the leak. Dt 1fiTR?BilYiON
<br /> SOURCE/CAUSE
<br /> .n<11:-a±`'- F , _If the form is completed by the tank owner or his agent, retain the last copy
<br /> sources) e, leak. Provide details on tank age: capacity and and forward the remaining copies in tact to your local tank
<br /> material if known. Check boxies) indicating cause of leak. for distribution. permitting agency
<br /> r TYPE 1. original - Local Tank Permitting Agency
<br /> rn dt at. the as. type ✓ita, 2. State Water Resources Control Board, Division of Water Quality,
<br /> y gory for this learc. Crecy one Dox only. Case type Underground Tank Program, P, O, Box ICC, Sacramento, CA 958C,i based on the most ;ens-ti ve respu roe affected. °or ex.,m+pie, if beth soil 3. Regunnai Wa±er Quality Control Board
<br /> and to L, vii ha he been affected, case type will be "Ground Water'. 4. County Bg,rd of Supervisors or designee to receive Proposition o`5
<br /> + i ea e `D .nking rater" only if one or core municipal or domestic water notifications.
<br /> ,e"S have a�:iF.al£p beer,- affected. A "Ground Nater" -designation does not 5. Owner/re sponsibie party.
<br /> Imply that rhe affected water cannot, be, or is not, used for drinking water,
<br /> but poly that water wells have not yet been affected. It is understood that
<br /> Case type may charge upas further investigation.
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