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INSTRUCTIONS
<br /> EMERGENCY Leak Seiza C.nr f9.rtacd='- Leak suspected at_s:i°we; but has not been r `irmec.
<br /> Indicate whether emergency 1 .1ui3 went dere l y e '' a. 'Z `
<br /> i-;.aoxas`e personnel -,n� e° ;:nv� �.�ecl� T'xe xir nor Site �s�.,essmen�'Ydo�ktai,�s�a sabr�aLe<: - pro �ns.�nl fres ase
<br /> at any rise.., If so, a a"ixza.r3u±as Material, Incident Report sl:gald'b'e filed f requested of/submitted by re pons tale party to determine Whether ground
<br /> with the St to Office o: lziacrseacv Services (OES) all'2960 MSeadow i::w Egad, water has been, or wall be, impacted as a result of the release.
<br /> Sacramento,',CA :5832,. Copies of the CES report S'arau may be obtained at �2derwav implementation of workplan,
<br /> your local ur_dergroulad storage tank lercaitting agency, indicate whetter YL)Ilution_2"haracteaxzation - re;po±±sible, party is in the process of fully
<br /> the OES renart has been, filed as of the z'.t.c of this report, defining; the extent of contamination in soil and g_ound hater and-assessing;.
<br /> .n acts on ,surface and/or ground water..,
<br /> LOCAL AGENCY ONLY, Rema,ieat-on i,Ian - remediation plar. sc,bmi:,ted evaluat-ing.iong, :tern,
<br /> To avoid duplicate notification pursuant to health and'Safety t;caae Section _ernadiat,ion options. Proposal and 1.nxil„m,.zztatic;n -„;z±.dula frai apT,,,o>,a,aae
<br /> 25180.5, a gyovernmen ern„ oyee should ziz;�a opal date the form in this block. renedia ion options also submitted,
<br /> A signature here dries not lean that the leak has been dete�n=wined to dose a lei i der�aav - implererit[atirn_of ronedi.ation plan.
<br /> sigxiificant threat to lz=.rnan health or sdfev, otaly that notification' Post Cleanu,n ?Icrxstor nF in Pi=ag�re s periodic ground water or other
<br /> procedures have been followed if rega leu r_0_axtori_.g; at site, as n, ,cssaay, to verify and/or evaluate effdc;iveness
<br /> of remedial activities,
<br /> REPORTED BY Case Closed - regsonal board and local agency in concurrence that. no
<br /> Enter yrau.x name, telephone nxnber,_-and address. Indicate which party,you' -further work is necessary at: the sita.
<br /> represent and provide company or agency name:
<br /> .r I`TOR ANT: THE,IWO?1,"v9ATION PROVIDED ON THIS T'Ckl•'.M IS INTENDED FOR .ENTE1lAL
<br /> P(3 TSTBLE PARTY `'' STATISTICAL PURPOSES 01 Y AND IS NOT TO BE CONSTRUED AS REPRESENTINGNX
<br /> Enter name, telephone number, contact person, ani address of the party OT'FICIA.L POSITION OF k4Y GOVERNMENTAL AGENCY
<br /> responsible'for the ?weak, The responsible party-would`normally be the tank
<br /> owner, REMEDIAL ACTION
<br /> Ziidicate which action have been used to cleanup or remediate the leak,-'
<br /> SITE LOCAT;fORT Descript,ioa* of options follow:
<br /> Enter—information regarding the .tank facility.— A' a Minimum, you must
<br /> provide the facility name and full' address. Lam e - instal' horizontal imperiaeablo Layer to redlace rainfall
<br /> infiltration.
<br /> IMPLE[ ITTNG AGENCIES Co_.tai,lment harrier - install vertical dike to block hor zontal1 move>ren'l of
<br /> Enter names of the .local agency :and .eg?ic res? Watoz Qual=i ty Control Board, nunv<aminant,
<br /> involved, �r Excavt±t4 an 's os - erove contatwnatci sail and di.s7o>,e "in aT,.;red
<br /> - r ..awe.
<br /> SUE.7ZAvCES 1 x7OL LD xExcavate and Treat remove contaminated soil. and treat (inclucles ,Lpiea';ing,
<br /> Enter the ora e and quantity lost of the h ziat.;ilaus substance involved, Roomo_r land farming).
<br /> a,s provided for information on t _.
<br /> two substsucs if appropriate. If more 'dean Remove Free Product - remove floating product from water ._,1...
<br /> two substances leaked, list tho two of most concern for cleanup. llum., and treat Grcurdwater generally employed to remove d.,:ao.t.ved
<br /> I1T,`"sCOVEKYfA3i1T.tME?r'j` tl:. w., 11_o.« a at:ion - Use-of any available technology to pro-note
<br /> :, ^7.. _ �
<br /> Irovid9 in ormati.on regarding th,e discovery and. aLatement of the leak. oacteriai decomposition of contarcina,.ts,
<br /> 11 - provide alternative writer supply to azs'ecM.d pazt..es.
<br /> 5OU21CF.LCAUSE r e.a'-,m P, t. a. ,.,n>ka5r. install water zecatrncnt :devises at each dwelling or
<br /> Indicate source .$) of leak. i",;eck box(es) ., :root x±g+Houses of leak, n*:.lair place of use,
<br /> V 3 c Extract use p+u ps of baowe ,ca'draa air through soil..
<br /> SE TPt �ci bore hole- in saw to al ow volati iza on of co-tam a >,
<br /> *-i_di.aytt.T"the ease type cater ry for this leax, Check ore boa: only. Cease Pao Action Reouirei - incident, is armor, re uoringno remedial act-on,
<br /> type is based on the Most se_sa t .e resource aff.ec:ed. For example, if
<br /> ,
<br /> both” soil. and ground water have been afar-c,.e_7, ,,; type pe will be "Ga_ot,cc, � C'�,2�..:F;."T
<br /> S Use: this space to elaborate on any aspects of the _xacidert.'
<br /> Wates". Indicate "Drinking Water" only if one°.or More muri cipai. or
<br /> domestic water Dells have actually been affected, A "Ground' Water„ SIG2iF. Sign she form in the space provided,
<br /> designation does not, imply haat the affected water, cannot be(, or is riot,
<br /> used for drinking water, but only t:auto wage* we.11z have not yet been T3IS RS�rs: ^vP;
<br /> affected. It is understood that case type May change upon further if the form is completed by the tank owner or his again" retain tbe 'a„u copy
<br /> invest:Lgaticia_ ea.uforward the �u aini g conies itxt<:ct�`tu y ur _ca a„�, izr � agency
<br /> for dlstribuivn.
<br /> CURRENT STATUS ” 1. Original - local Tank Permitting Agency
<br /> Indicate tiae category which he,„ iesc w E, !h_. status of tx.e case, ra_ _, is saaz:es c r i o__ Board, Division of Clan ;,.ac r Pro
<br /> ,
<br /> Check one box only. The xero,a.,; , h3.:i zc r .L<st. re to ttae caw t r` .'t res e Tank Program, Box >rz ?2; ,.< ;. 9.2
<br /> example. if as type "Gr.,i,.,h :s;t
<br /> v;
<br /> to the status of the ground waosr';±a n,,,,, a _JiccA(ax L.._.aatag, as Ien os'-d >..o ?_ t nes 'W
<br /> . at ` Quality Cc ,<a
<br /> .mtro_ �e
<br /> u
<br /> that of soil. , a+ Local Health O fi=ler and Count ?ca, !
<br /> k ion
<br /> Pio F n r si' - ,i4r tack,,, r t_K....; byres,on>_.L,Se Y ,.s a.'::� 5.
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