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71 <br /> INSTRUCTIONS k� 'i 1''�; t. � '-'1„ <br /> M; R"= # CURRENT STATUS <br /> EMERGENCY t I <br /> ndicate whether emergency response personnel and equipment were involved at "` q n Check <br /> on C e category which best describes the current status se the case. <br /> r any time. If so, a.Hazardous Material'Incident Report should be filed with Cheek one box only. The response should be relative to the case type. For <br /> the State Office'af Emergency Services.{OES)r at 2800 Meadowview Road, �` i S example, if case type is. Ground Water", then "Current Status" should refer to <br /> Sacramento, GA 95832. ,Copies of the DES report form maybe obtained at your?' the status of the ground water investigation or cleanup, as opposedrta that of <br /> local underground storage tank permiIfting agency. Indicate whether the DES ^' soil. _ f <br /> E <br /> report has been filed as of the date'of this report. & - 1 s <br /> x p IMPORTANT: THE INFORMATION PROVIDED ON THIS FORM IS INTENDED FOR GENERAL r <br /> f <br /> J 5 STATISTICAL PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REPRESENTING THE <br /> LOCAL AGENCY ONLY, <br /> o avo, duplscate notification pursuant to-Health and Safety Code Section � " OFFIGIAL PDSITION_OF ANY GOVERNMENTAL AGENCY e e 'f <br /> ( 25180.7, a designated government employee should sign and date the form in <br /> this block. A signature here does not mean that the leak-has been determined REMEDIAL ACTION , <br /> to pose a significant threat to human health or safety, odly that notification <br /> Indicate which actions!have been used to cleanup or{remediate the leak. <br /> procedures have been followed if required. Descriptions of options follow: <br /> # REPORTED BY { t r C-ap Site - install4'horizontal impermeable layer to reduce rainfall F <br /> infi tration. <br /> Enter your name, telephone number, and address. Indicate which party you <br /> represent and provide company or agency name. ti - -C 1` Containment Barrier - 'install vertical dike to block horizontal movement <br /> of contaminant- fd <br /> RESPONSIBLE PARTY . Excavate and Dispose - remove contaminated soil and dispose in approved <br /> Enter name, telephone number, contact person, and address of the party site. , { I <br /> Excavate and Treat - remove contaminated soil and treat (includes <br /> responsible for the leak. The responsible party would normally be the tank , <br /> d <br /> owner. ' 4- spreaing a and farming)• <br /> t 1 Remove Fre .`R roduct - remove floating product from water 1*4 <br /> SITE LOCATIONi -� to e. 4 i <br /> Enterrmation regarding the tank <br /> ontaminants. <br /> -facility and surrounding area. At a I Pum and Treat Groundwater - generally employed to remove dissolved ip <br /> minimum, you must provide the,facii,ity name and full address. !' <br /> c <br /> . Enhanced Biodegradation'- use of any available technology to promote <br /> ` :.t i bacteria decomposition of contaminants. <br /> IMPLEMENTING AGENCIES ' + . ` <br /> rater names.o the local agency and Regional'Water Qu ality_Control/B'and s _t Replace Supply - provide alternative water supply�to affected i <br /> involved: <.., parties. dwelling <br /> # <br /> i Treatment at Hookup - install water treatment devices at each dwelling or <br /> SUBSTANCES INVOLVED q y_ - of e.r place o use. 1. <br /> Enter the name and quantity lost of the hazardous substance involved. Room is No Action Required - incident is minor, requiring no <br /> provided for information on two substances f'f appropriates. If more than two regia action. <br /> e - � <br /> substances leaked, list the two of most concern for cleanup. -; <br /> 1 COMMENTS Use this space to elaborate on any aspects of the incident. <br /> " r SIG�E - Sign the form in the space provided.' <br /> DISCOVERY/ABATEMENT s <br /> f, trovide information regarding the discovery and abatement of the leak. ^y DIS1R 3�U7[ON i N__{ ; <br /> SOURCE/CAUSE F' � 1 r 4 If the form is completed by the tank owner or his agent, retainItne�last Copy <br /> Indicate source(s) of-leak. ..Provide details on tank age; capacity and and forward the remaining copies in tact to your local tank permitting agency <br /> material if known. Check box(es) indicating cause of leak. i for distribution. + <br /> s , 1. Original - Local Tank Permitting Agency <br /> CASE TYPE { ;! �,. t. <br /> 2. State Water Resources Control Board; Division of Water Quality,! <br /> Indicate the case type category for-,this leak. Check one box only. Case type Underground Tank Program, P. 0. Box'100, Sacramento, CA 95801-; <br /> 3. Regional Water Quality Control Board <br /> is based on the most sensitive resource affected. For example,:if both soil <br />' f 4. County Board of Supervisors or designee to receive Proposition 65 <br /> and ground water have been affected; case type,wi-11 be "Ground Hater'. <br /> Indicate "Drinking Water" only if'one'or mpre municipal er domestic water , � -. notifications. <br /> S. Owner/responsible party. <br /> wells have actually been affected. A "Ground Water"Idesignation does not # a f <br /> r1 imply that theaffected water" > <br /> cannot be, oris not, used for drinking water, +' 4 <br /> 4 but only that water wells have`not yet been affected. It is understood that_ ` t , <br /> ' case type may change upon further investigation. <br /> f rd <br /> k <br /> 14 <br />