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INSTRUCT'ONS EMERr.ENCY , C URREIt STATUS >tih tl r errs.gercy response personnel and equ i;,meat were involved at gdtcate the. category which best describes the current state a ere se, a iarareous Irate i i incident Report should be filed with s of the- Ca So. . ire St"". Office of c - Check one box nrly. The response shou7C be relative a r-}ae ,;ase typo. For rx.ge ncQ Ser,+ ars r(iES t 2r 0 plea dewvfew Raad, exnnpl±. if case type is 'Ground Water", then `Current Stat,rs' should refer to iicra n-ntO CA' 95832 melees. of Vioc OLS repot fern may be obtained at your the status of the ground water investigation or cleanup, as Opposed to that f to-.. .dc..rgr mord stera,le tank permitting ag ncy. Indy- to whether the GES sail, p report has been filed as of the date of this repoAt. LOCAL AGE;;C'{ ON!Y !MPORTANT: THE INFORMATION PROVIDED ON THIS FORM IS 1NTENOEQ FOP. CENERAL To avoTT c dr are notification pillto health and Safety Code Section STATISTICAL PGSFTRPOSuy ANYYCAN3 I lENOT TO BE CONSi'RUED AS REPRESENTING TH.. 7A SJ.J, i rinsianatee go+crnmert Em(ld Once should sign and date the form in OFF ° AL AGENCY t s tr sc4 s anon'a here I Des Patmean t z. th- leak has been de- mf nets R tEr rAL .CTl OR to PO- a sinlfcant threat to'Nihioa7rincaltry Or safety, only that netificat-on nota e wTcfi actions have been used tc cleanup or renrediate tne- p ocndurfs av been followed if required. Descriptions of options follow: Y leak. REPORTED BY Fnt r oil "n>ne, Can Site - install horizontal impermeable layer to reduce rainfall Y vi telephone nur,Aier, and address. Indicate which party you tnFiTf,ation. represent and provide company or agency name. Containment Uerrier - install vertical dike to block horizontal egveiro,t RESPONCIBLE PARTY En era d: -�leohnne ru..d>er contact n<;rsor„ and address Of the party Excavate and Ui spore - reriove contaminated sell and dispose in approved ! ,ponsihle or the leak. The responsible party would normally be the tank Excavate and Trea owner. t - remove Contaminated Soil drd treat ( n lud<s so'eadTng or Tamfarming). SITE LOCATION' Retrieve Free Product - reCkive floating product from water En*:mor matien regarding the tank to:iii" table. •y and surrounding area. At a Pump and Treat Groundwater - g-nerill,y employed �O reuxwa dissolved minimum, You .west provide the Pacili*, name.and full address. CO!aaini l„ants. TIPLEMENT 114G AGENCIES Enhanced Ciode tadation - use of an_: available technology to promote cn+=�manes OV7 local agency are, Regional 'dater Quality Control Board 6acitlriaTdec—p�mposttion of contaminants. .nvolved. Replace SupL3l_ - provide alternative water supply to affected ' - partici. SUBSTANCES INVOLVED - Treatnnnt at lookup - install water treatment devices at each dwelling or `!it rthe iameiri-Ic gua nti ty last of the havardous substance ic�vo'vnd. Room is otTter prate of ase. provided f N6 AC ti On�guired - incident is minor, requiring no p O irformition on two substances if appropriate. if more than tv+¢ remP� artinn. Substances leaked, list the two of Most concern for cleanup. _ SCOVed 111AIEME_NT C(H,FHTS - Use this space to elaborate on any aspects of the incident. Si7`-ASR` - Sign the farm in the spare provided. provide tnforma ti¢h re3arai ng Lfle discovery and abatement of the leak. ALIS �UE19ti SOURCE/CAUSE Intl'i ateJsoirrce(s? of le.`. P r p g If the form is conif tad by the tank owner or his agent, retain the last copy to esv de. details on rano :;one; a icit and Weed forward the remaining copies in tact SO your local tank permitting agency material if knawn. Check hox(esl indica ti n9 cause of leak. for distribution. CASE TYPE - 1. Original - Local Tank Permitting Agency ins a the case type catigory for tns lean -heart oney. 2. State Water Resources Contre7 Board, Division of Water Quality, is based on fi lost sensitive resource affected For example, if baths soil 3 RUnderground ergr and rank Program, P. 0, Boz 100, Sacramento, CA 9580'. ad e ,una wit:.. hi one - ..n affected, rase type will re °Gree^d '+.'a ter'. g e. Quality Control Board 'nail e "Or nkiro Water” i 4. notifi Board of Supervisors or seri ghee to retrive Prupcsi ti on i>5 gni e if one as more municipal baa Or riamesiie. xater notifications. Boards. 'we' .;ave actually beta., affected. A 'Ground Water' designation does not !i. Owner/responsible party. 1pi1 that the affected water cannot he, Or is not, used ren drinking water, butt'. Only that water wells have not vat been affected. It is understood that .case type myc change upon further investigation.