SITE INFORMATION AND CORRESPONDENCE

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r F INSTRUCTIONS EMERGENCY CURRENT STATUS ndicate whether emergency response personnel and equipment were involved at Check aon the category which best describes the current status of the case. any time. If so, a Hazardous Material Incident Report should be filed with Check one box only. The response should be relative to the case type. For the State Office of Emergency Services {OES) at 2800 Meadowview Road, example, if case type: is "Ground Slater", then "Current Status" should refer to Sacramento, £A 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. IMPt;RTA'dT: THE iNFQR3-iATIOAt PROVIDED ON THIS FORM IS INTENDED FOR GENERAL STATISTICAL PURPOSES ONLY AND is Nor TO BE CONSTRUED AS RZPRESE44TING THE LOCAL AGENCY ONLY o avo d dup irate notification pursuant to Health and Safety Code Section OFFICIAL POSITION OF .ANY GOVERt1MENT.4L AGENCY 25180.7, a designated government employee should sign and date the form in this block. A signature here does not mean that the leak has been determined Inairate w se actions have been used to cleanup ❑r remediate the leak. DIAL ACTION to pose a significant threat to uman health or safety, only that notification c Descriptions of options follow: procedures have been followed if required. REPORTED BY Ca Site - install horizontal impermeable layer to reduce rainfall nteContainment fir your name, telephone number, and address. Indicate which party you ltration. mo represent and provide company or agency name- Containment Barrier - install vertical dike to black horizontal vement of contaminant. RESPONSIBLE PARTY Excavate and Disoose - remove roncaminated 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 spreading or-"-'and"Rfarming)- owner. Remove Free Product - remove floating product from water SITE LOCATION table. nter cn,ori�ition regarding the tank facility and surrounding area. At a Pump and Treat Groundwater - generally employers to remove dissolved gtaminimum, you must provide the facility name and full address. Enhanced - - use of any available technology to promote IMPLEMENTING AGENCIES bacteriompotion of contaminants. Enter names o the oral agency and Regional Slater Quality Control Board Re cp'ace Sully - provide alternative water supply to affected involved. parties. treatment at Hook 1 - install water treatment devices at each dwelling or, SUBSTANCES INVOLVED other pJ� ace of use' nker the name and quantity lost of the hazardous substance involved. Room is No Action_ R d incident is minor, reCuirir.g no provided for information on two substances if appropriate. If more than two reme.ca action' substances leaked, list the two of most concern for cleanup. COMMENTS - Use this space to elaborate on any aspects of the incident. DISCOVERYIABATEMENT Iou RI - Sign the form in the space provided. rov de information regarding the discovery and abatement of the leak. IoN If the form is completed by the tank owner or his agent, retain the last copy SOURCE/CAUSE Indicate source($) of leak. Provide details on tank age; capacity and and forward the remaining copies in tact to your local tank pernnitt?ng agency material if known. Check box(es) indicating cause of leak. for distribution. 1. Original - Local Tank Permitting Agency 2. State Water Resources Control Board, Division of Water Quality, CASE TYPE n—dTc to the case type category for this leak. Check one box only. Case type Underground Tank Program, P. 0. Bor. 100, Sacramento, CR 9580I is based on the most sensitive resource affected. For example, if both soil 3. Regional Wafer 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 rotifications. wells have actually been affected. A "Ground Water" designation does not 5. Owner/responsible party. 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.