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INSTRUCTIONS
<br />040' GElki"Y
<br />CURRENT STAIRS
<br />?
<br />,riz .Lrr wn.Gi,er-meracr,cy response er•sonnel and equipment were involved at
<br />:'idz e.. 41 Category which t3:'.sF describes T.hf ::Urr€'lt si$PU$ }f ttlC case.
<br />arly timesot a azardous Material Incident Report should be filed With
<br />Check one. box only. The response- should be relative to he case type. For
<br />"'.
<br />Office
<br />the State O ie of mroency Services. 00.53 at G C0 fieadowview Road,
<br />Azar€rn,.a, fif case type is "Gground Water"., then 'Current Status" should refer to
<br />w
<br />Sacr?Feng), CA 95£132. ,..Copies of t;Cie OES report for€r may be obtained at your
<br />the status of theground water investigation or: cleanup, as opposed to that of:
<br />local undi!rgrourid storage.. tank pernttting agency. Indio-ate whether the OES
<br />sall.
<br />report has been filed as of the ,date of this report.
<br />TPE INFiIRMA,ri£)Pl PROVIDED ON' THY r"CRS" IS INTEENCED_FOP GENERAL
<br />LOCA! AGENCY ONLY
<br />STATISTICAL PURPOSE'S ON!'
<br />Y .AND IS U0€ TO BE CONSIRUED AS REPRESENTING THEto
<br />aao # d;#.l .ca se notification Pursuant to Health and Safety Code Sectiotl
<br />OFFICIAL POSITIONOF ANYGOY<.i?NMENTAL AGENCY
<br />2 18'u J', a destanated government employee should sign and date the from, p
<br />this bloom. A 5tgrlat,€are here does not :Elean that tl;i .:leak has i)�"£:n Cit�ier'r4t n�.'€.
<br />Rf R
<br />REMEDIAL IAL ACC* �i
<br />to Pose w Significant threat ro h#:r ar ?te.aitn or safety, Only that notification.ri
<br />£Sl y;a tL'. v:hich a€;t10r€s have been used to clean€ip or remediate .the leak,
<br />procedures have been followedifr€auired.,.
<br />CCs€ripti€ns of options follow.
<br />REPORTED BY
<br />Can Site install horizontal impermeable layer to reduce rainfall
<br />Errtrr yo€ts na€tom, telephone number, and address. ' indicate Which party you
<br />t, ±Mtratiun.
<br />represent and provide company rzr`agency name.
<br />Containment Barrier - install vertical dike to block horizontal m. vein-int
<br />oT€.o l*.amt:€ant.
<br />RESPONSIBLE PARTY
<br />Excavate and Dispose remove contaminated soil and dispose in approved
<br />'
<br />Fnte. name, to) leptloner nuilber, contact person, and address of the party
<br />s.tee
<br />l e ;.
<br />responsible for, theeak.- The responsible party would n€zrtnally be the tan
<br />excavate and Treat - remove contaminated sail and treat (includes
<br />owner:
<br />ssi€reading cr'land—farming).
<br />iteivve Free Product - re#:xave floating product from water
<br />SITE £l
<br />.. _£.,1 i ION'
<br />__. ... _ _.._
<br />txf €
<br />En r,F In-crsiztlon re£iard n, the tank facility and surrounding arra, At a
<br />Pump and ireat Groundwater - generally eisployei to rel,±ova dt=rsolved
<br />ttlint4'it11"i,, .you sn€#$; prnvt4ae the facility name and full address»
<br />cor^talrttar?rs,
<br />Enhanced Biode2radai on -case of any available technology to promote
<br />t sg n t
<br />III' dri EMENI I G AGENCIES
<br />baf tE i a r€}is �i 2€)= o Cori t*fmi na nts.
<br />agency and Regional Water QuIlity Control Board '
<br />Replace Supply - provide alternative water supply to affected
<br />toYo€ved..
<br />___. _
<br />t}3P"..tT ZS. ..
<br />r
<br />Tr_eatme^�nt at_3li kup - install water treatment de.v;ces at Each dwelling or
<br />SUBSTR iNVOLVED
<br />r'Ftt r tNF name ,land quantity les`. of the hazardous substance involved. Roon is
<br />ho Ae�t zn Rwired - 'inCiclent is minor, requiring no
<br />provid€d for information on two substances if appropriate. if more than two
<br />reF,.eSii+T ai;ttcn.
<br />s,#bs ar cs' lezkx d, list .the two of most concern for cleanup.
<br />COMMENTS Use this space to,.elaborate on any aspects of the incident.
<br />'
<br />SCOVER YiABA€EMENT
<br />_ _
<br />Prckzda znf,ar€,..sten regarding tete discovery and aoat:.lr#cnt of the l teak.
<br />Sir�4R''vRE - Sig the form ip the space provident.
<br />iIIm16U!I,N
<br />,
<br />'SOUR CAUSE
<br />If the form is coCs-pleted by the tank owner or his agent, re asn<the last copy
<br />:a Yids iter 'source(s) of le.i;. Proviolf. details on tants age.. capacity and
<br />and forward 'he remaining Copies in 'act to your local ac�°tK pe!"i!P?tti??g aC�f'.nCy
<br />_...
<br />;?aa tsw >°sal -3 if known. Check sPCX t'eS? indicating ca€#$e of leak,
<br />for distribution.CA .
<br />i. Original - Local Tank Permitting Agency
<br />cr Tyro
<br />2. State Nater resources Control heard, Division of 'Water Quality,
<br />..
<br />lndtat,—the case type category for* t=lis lei=k. Check one box only. Case- type
<br />Underground lank Program, P. 0. Box 100, Sacramiento, CA 95$01
<br />is based on the most senssive resource:. affected. For example, if both soil
<br />?< Regional Water Quality „'entre{ Board
<br />and ground water have beer': affpcte€i; care t .e Wil€ h{i °mound `n'aterrs,
<br />4§ County Board of Supervisors or iesi`gneet t€; receive Pro osition t}3
<br />:0, °. . .
<br />...and?€.a„e urtrzktrPo ��.t€ar” only ;f on,. or rune, <nunzcirPal or domestic water
<br />notifications.
<br />wells have ac l ialTy been affected. A "Ground Water" designation does not
<br />5.Owner/responsible party.
<br />imply that the arse.tec4 Water cannot of,,, emits not, used ler drinking water,
<br />put only that water wells have hot yet been affected. It is understood that
<br />cas, type may change upon further investigation.
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