SITE INFORMATION AND CORRESPONDENCE_FILE 1

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INSTRUCTIONS _ EMERGENCY _ _ - CURRENT STATUS rfd c7 ate whether emergency response personnel and equipment were involved at - n tcate t e category which best describes the current status of the case. airy time. If so, a Hazardous Material Incident Report should be filed with Check One bort only. The response should be relative to the Case type. For Sacrament, CAthe State Ce95832.of Copiesency 5ofvthe sDES E report 28orm00 M may be!Obtaew ined at your example,statif fOC se tground e is "Groundwater Water", theion or cleanup,Status"Dshould refer to of local underground storage tank permitting agency. Indicate whether the DES soil report has been filed as of the date of this report. _ _ LOCAL AGENCY ONLY _ IMPORTANT: THE INFORMATION PROVIDED ON THIS FORM IS INTENDED FOR. GENERAL STATISTICAL PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REPRESENTING THE TOTO-avn7 dd-nticate notification pursuant to, Neal th and Safety Code Section OFFICIAL POSITION OF ANY GOVERNMENTAL 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 REMEDIAL ACTION ` • - l to pose a significant threat to uman health or"safety, only'that not)"Fication - n icate whlc actions have been used to cleanup or remediate the leak. procedures have been followed if required. Descriptions of options follow: _ ) REPORTED BY - Ca Site - install horizontal impermeable layer to reduce:rainfall I Enter—your name, telephone number, and address. Indicate which party you - n v tration. - - - represent and provide cmpany Or agency name. - Containment Barrier - install vertical dike to block horizontal movement RESPONSIBLE PARTY - - - 0 conte aT— Excavate and Dispose - remove contaminated soil and dispgseid approved Ener name, to - one nuolber, contact person, and address of the party - 1 site. - - rO POnsihle for the leak. The responsible party would normally he the tank Excavate and Treat - repave contaminated soil and treat (includes owns _. _ --spree in or_ ar. farming) SITE LOCATION - Rerve Free Product - remove floating product-from'water . to-aTTe.— - - Enin, you tion regarding the tank Gari lity and surrounding area. At a - - - Pnmp and Treat'Groundwat - generally employed to remove dissolved m nrmum, you must pro¢ide,the facili y name and full address. - E.otam rants.Enhanced Biodegradation --use of any available technology to promote IMPLEMENTING P.GENC IES. . bacterial decompo--sttio!i of contaminants.' nter names o the xal agency and Regional 'Water Quality Control Board Replace Supply - provide alternative water supply t affected involved. - parties. . -I 1- _ - ' Treatment at Hooku - -iinstal water treatment['devices at each dwejling or SUBSTANCES INVOLVED - of er p ace o use. _ n� the name an puanti[y lost OF the hazardous substance involved. Room is No Action-Re9ul red incident is minor, requiring no substiec for ip Formatirn on two substances if appropriate. If'more than two remedial actron. - substarces leaked, list the two of most concern for.cleanup. �' - ' DISCOVERY/ABATEMENT : ! COk4dENTS - Use this space to elaborate on any aspects of the incident. Provi -- i y SfYUAME - Sign the form in the space provided. de m ormatign regarding the discovery and abatement of the leak. - MR-MrION 50 RCEJLAUSE ! r-;'r ty,,. .if the Form is cxplatOd by'the tank owner Or his agent, retain. thlast.copy In ate soarcefs) of Leak. Provide details d-.on tanii age; capacity an '.'and forward/Is remaining copies'in tact to your local tank permitting agency -material if known Chetk box(es) indicating cause of leak. for distribution -- _ - i - '4 ` �T- Original Local Tock Permitting Agency SASE TYPE: - ' ' 2. State Water Resources Control Board, Div!sion'of Nat r Quality, nd3Tcate the case,type_cat gory for this leak. Check one box only. Case type Underground Tank Program, P.;O. BOX 100Sacrarento, CA 9580 i is based:on +hg most sans tiv2 resource affected. For example, if both soil 3. .Regional Nater quality Control Board .,_ ;and grc.;nd water have beer, affected, case.type will he "Ground Nater". - A, County Board of Supe,visors.qr designee ne to to j Indicate 'Dn nking Water Only ifione or more municipal or domestic water notifications ! S• calve Pro posr trion 65 I1 1N, lls have actual)y bean affected. A .Ground Water* designatidn does not 5. Owner;responsibl far y. L j �ly that the-affected water-cannot be d is not, used:for drinking water, j ibutionly thai-water wells have not vet,been--affected. It is understood that ease type may cFiangO upon further investigyion. - - r f ' ' ii T .o �•r j) ^ v