SITE INFORMATION AND CORRESPONDENCE_FILE 1

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EMERGENCY INSTRUCTIONS CURRENT STATUS n irate whether emerger{cy response personnel and equipment were'involved at n irate t e category which best describes the current status of the case. any time. If so., a Hazardous Materfal Incident Report should be filed with Check one box only. The response should be relative to the case tyle. For the State Office-of Emergency Services (DES) at 2800 Meadowview Road, example, if case type is Ground Water", then 'Current Status" should refer to Sacramento, CA 95832.- Copies of the DES report form may be obtained at your the status of the ground water investigation or cleanup, as opposed to that of local underground storage tank permitting agency.` Indicate whether the DES soil , report has been filed as of the date of this report. IMPORTANT: THE INFORMATION PROVIDED ON THIS FORM IS INTENDED FOR GENERAL LOCAL AGENCY ONLY STATISTICAL PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REPRESENTING THE TO-7v-0-776—plicate notification pursuant to Health and Safety Code Section y OFFICIAL POSITION OF ANY GOVERNMENTAL AGENCY 25180.7, a designated government employee should sign and date the form in REMEDIAL ACTION this block. A signature here-does not mean that the leak has been determined . tate w is actions have been used to cleanup or remediate the leak. to pose a significant threat to human health or safety, only that n notification Descriptions of.opti ons followr- procedures have been followed.-if required. ) .- REPORTED BY - Ca Site - install horizontal impermeable layer to reduce rainfall ntel r your name, telephone number, and address. Indicate which•party you infi tration. Containment Barrier - install vertical dike to block horizontal movement represent and provide company or agency name. o contaminant. RESPONSIBLE PARTY - Excavate and Dispose - remove contaminated soil and dispose in approved Enter name, telephone number, contact person, and address of.the-party site. responsible for the leak. The responsible party would normally be the tank - Excavate and Treat - remove contaminated soil and treat (includes owner. sprea ing or an farming). Remove Free Product - remove floating product from water SITE LOCATION .- tane. nte€r 7formation regarding the,tank facility and surrounding area. At a _ Pump and Treat Groundwater - generally employed to remove dissolved e tac minimum, you must provide facility name ,and full address. _ contaminants. _ Enhanced Biodegradation - use of any available technology to promote IMPLEMENTING AGENCIES bacteria ecompositi on of contaminants. Enter names �e local agency and Regional Water Quality Control Board Re lace Su ly - provide alternative water supply to affected involved. - part es. Treatment at Hooku - install water treatment devices at each dwelling or SUBSTANCES INVOLVED oL�p ace o use. No Action Re wired - incident is minor, requiring no Enter the name and quantity lost of the hazardous substalfce involved. Room is _ 9 provided for information on two substances if appropriate, If more than two reme—dial action. substances leaked, list the two of most concern for cleanup. COMMENTS - Use this space to elaborate on any aspects of the incident. DISCOVERY/ABATEMENT - SINE - Sign the form in the space provided. Provide information regarding the discovery and abatement of the leak. e DisWTIBUION SOURCE/CAUSE _ If the form is completed by the tank owner or his agent, retain the last copy Indicate source(s) of.leak. Provide.Qetails on tank age; capacity and and:forward theremaining copies in tact to your local tank permitting agency material if known. Check bdx(es) indicating cause of leak. for distribution , 1. -Original - Local Tank Permitting Agency CASE TYPE 2.:State Water-Resources Control Board, Division of Water Quality,Underground Tank Program, P. 0. Box 100, Sacramento, CA 958019501 In i--3`cate the case type category for this leak. Check one box only. Case type : 3. is based on the most sensitive resource affected. For example, if both soil Regional Water Quality Control Board and ground water have been affected, case type will be "Ground Water". - 4. County Board of Supervisors or designee to receive Proposition 65 Indicate "Drinking Water" only if one or more municipal or domestic water _ notifications. 5. .-Owner/responsible party. wells have actually been affected. A "Ground Water" designation does*not imply that the affected water cannot be, or is not, used for drinking water, . but only that water wells have not yet been affected. It is understood that case type may change upon further investigation. - _ "