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I No I PI ICC 101M
<br /> t; EP1E'RGENCY - Lcak being Confirmed - Leak suspected at site, but he;f nn`. he•
<br /> Indicate whether emergency response I:n confirmed.
<br /> g y p personnel and equipment were involved- requested
<br /> Site Assessment sPOns Lan Submitted - wo roposat
<br /> h. at any time. If so, 'ti Hazardous Materi al.Incident Report should he filed requested of/submitted by responsihlo Party to int •-J .•thnc ground
<br /> with the State Office of Emergency Servicers (OES) of 2808 Me.ado�rvlew Road. water has been, or will be, imnarted as a re, tW$ L ', -: ;=).eeso-
<br /> Sacramento, CA 95832. Copies of the OES report form may be obtained at It's
<br /> _im nary Site Assessmegt Underwe, implo.el,,,l :. ,.: „f 'ror'kii
<br /> -your local underground storage tank permitting agency. Indicate Ihethar I_ollsit on Characterization - responsible.party _o process of fully
<br /> W the OES report has been filed as of Lice date of this report, Ca+i.+ �g t!.: a::tent of contamination +n +I .,.,ter and assessing
<br /> :its •dace and/or ground
<br /> LOCAL AGENCY ONLY _ i (� "leu - remedia.,ion plan '•.v term
<br /> 'Io :avoid d,tplicate notification nt¢:,pant to Health and Safety .'ilio S,iti,rl •f . rti.ons. Proposal and ir� f n' aFrpropriete
<br /> 25180.5,-a government employee should sign and data the form in flits block. r6innd alfa suhnd triad.
<br /> A signature h r. do_s !lot qt nrthat tale Leek has been d�tcnnined -. pose a rl :,toy - im f
<br /> cl.enrta �+t o_
<br />: Lgil icrva 1 'it, l,i i cutup hulls'• I -..tory, 'nn1v that uatifi.catJ:-n P;onitot: 11-11-ass.
<br /> pro,,.. . - i, _ .i ! t .
<br /> PEPOi ED J,iY '
<br /> EoLer - x+ : .1 . .. no
<br />- your , „hone - �,. ..•'-+cess. Indicate which e.tl ; -. 'ar:l
<br /> Pt en t. • ':, nn pcl r. , S name.
<br /> roll , , n 1
<br /> ESE NS ibt.F ;TJi,i I t.,l..� II. 1 I I(l *:
<br /> mmnu, r.hnlo nymber, cont cL r=rsc.n, and addre ..f ..h.: ,-r,-: -?A', F -;^” Y 11 f•.I. AG;CN:',
<br /> ••J-'LsiAL� L '.hT 111a)[. -Tha reayrr—'.I J.n pa-t:v -,:•,u1d I, hall;
<br /> p
<br /> .,i to .;J oat•-p
<br /> IT_ LC_CATToN -
<br /> Enter information regarding the tank frn.;i.'.ity. At a m pl'•r•. -o *.
<br /> provide the facility nameand full address:. at S•+ n,-A 11 'roc i ....I I re -D:..b]" ].mrcr to <,: ".. ,.•'.,1).
<br /> _.;n,
<br /> IMPIEhJENTING AGENCIES Cont.11t }farrier i.netrl .:_tical dike to bi fit,, 1I my ^rcpt of
<br /> cut r names of the i.pral agency and Pe.eional linter Quality Contr-1 b..m'r c nt:n- t tit.
<br /> t.nvoJ ed. Eicx-vate ud Dia olio remove crit. inet J noi.F. it,i 1.- in f ;+•:d
<br /> STY, i -LACES INVOLVEU � - 'I, � - r.`-aurin=1 d ,o.t. ,u
<br /> the name and maantit,y lust ':.f Uhl, hazardous
<br /> is provided for information on two subetanoes 1f app.^ rete. Etr,
<br /> : tea substartai .leaked, list the two of most, concern for cleanup, •.L' w , • a _,1.,..,,;
<br /> J15rC,_�ERY/A[+TG_MEIiI I •' .'a r, ct'r•.-m Pr ,:not
<br /> Irovt.ria bd�l met ion rpardine ,
<br /> - , tIr d�scov easy and ab at.emn•ir of the _
<br /> it rpt 1 r kta:
<br /> OIF P CAIi R' ' ,h • t n - -
<br /> %e(-;) of. _eek. _.. ok l'-:es) .nli.cating F. ol-
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<br /> ' r i•ID:psc FI W-:> jt ri G•.
<br /> ,: t, K I. -ir ( ruin r 1 II r 1 J r 1 ,t_,
<br /> h
<br /> +t. Ire the case
<br /> -p ih .-..: 1 7., rl :: ilii, ... cid ,. �-
<br /> tY:.., is hosed on e nl t :1" t ,I•f. . i t - _ _ -
<br /> slid gt I .-. (. ^.•n r '• _ 1'., _ :,n:r to eI-sera4e On an' a.,:�, - :e,',I.
<br /> Indicat• 1;:�. t r sim:o 1• .
<br /> ater u-.1 q ^.,.r• .. ,.1„ •rl in t:!:., spare prrvi,).,d.
<br /> r=v doe
<br /> ..:- irrnkir.F
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