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<br /> INSTRUCTIONS
<br /> EME w 'wY eac 23ein Canfirmerl - Leak suspected at site, but has not been confirmed.
<br /> t, Indicate whether emergency response personnel and equ pment were involved Freiimiraar Site Assessment ear nlan Submitted aor pianfpr�posal
<br /> at any tsme. 3f so, a Hazardous Material Incident Report should be filed requested of/submitted by responsible le Isar y to determine whether ground
<br />'~ with the State Office of Emergency Services (CRS) at 2800 Meadowview Road, water has been, or will be impacted as a result of the release.
<br /> Sacramento, CA 95£332. Copies of the OES _fort foam may be obtained at Pre,xfm -Ial:y Ste As e srez,t Underwav implementation of workplan,
<br />' your local underground storage tank permitting agency, Indicate wheth=ter Pollution gharacterlzafion - responsible party in the process of fully
<br /> the. O:.5 report h, been filial .as o& the ace i>izs report, defining ,
<br /> the extent of contamination in rata and ground water avid assessing
<br /> impacts €n1 surface and/or ground wwter.
<br /> TCCA_. A ttCY CHLy Rearediat oaa Plan - media asn ralsr sc m ta;e erra_iat, ng long 4;erm
<br /> To avoid duplicate notificaitian pursuant to Health and Safety code lection ramodiat.ior, optionsz Proposal and implementation schedule, for appropriate
<br /> 25180,5 a goverrLment employee should sign and :late the farm in tilts block. remediation, cations also submitted,
<br /> A signature here does not mean that the leak has been determined to pace a 911eanup ' derwa v of remediatjorl
<br /> significant threat to human health at, safety, only that notification vost, Cleanup a M cr in o .e s periodic i round l waa.er or other
<br /> ito ng a, site, az necesse y, o ierdry ar-d/,or evaluate affeet4o -a s
<br /> produies have been followed if recfiirei,
<br /> of remedial actzvit--'eN.
<br /> :REPORTER BY Case Closed - regional, bv=ald and local agency it concurrence that no
<br /> Enter yon r op
<br /> name, telhone num-her, and eaddress, Indicate which narty you further walk is n ceasary at the s tse.
<br /> rexire rent and provide company of agency name.
<br /> M'2' -At `aHENF ^�OR"1r3TlON PRa V D ON eC rSFORM, S N 'DED FOR CENE'EIj�L
<br /> RESPONSIBLE PARTY STATISTICAL PURPOSES ONLY AND l02 O p. +.ler3 iSillED Ad REPRESENTING HE
<br /> Erate a a'me, .eleohore number, contact; p=erson, and eaddre,,s of he pca:s ty T> P ITION G_° A�„ CSV e:'., L t§1 ,I.: A,v
<br /> respc,nsable for the leak. The responsible party wr:al_d r.oxmally be the t4..
<br /> owner, REMEDIAL DIA ACTION
<br /> dicta tw whai.,b action he c b,_n, iced to c�ea p ,a m madiate the Is,
<br /> STTr, LOCATION e ci.np-Ons of OFUzcns t.tf_13w°
<br /> Hnber iaformation regarding the taxik facility, At a r.,inivacvC, you Tlust
<br /> provide t o taoility namd and full address, far Site ustrai' horizontal im ermeab , hays to reduce rainfall
<br /> infiltration
<br /> IMPLEMENTING AGENCIES C"ontoairucent Barrier instal-1 vertica-1 dike is block borizontal movementnmovementof
<br /> '
<br /> ntar names of the .Loral: agency and Regional Water Quality Control, Board contaminant,
<br /> involved. Excavate and )iso sl rcc�,o e c an
<br /> G inall d soil, and dispose in approved
<br /> site.
<br /> SUBSTANCES TPrJIaE ,xcti Yoe j ix2 n remove soJI, and treat (includes spreading
<br /> Enter the name and quantity lost of the hazardous substance in`ol"Vt cic loom 0,r ' ori m Ing)
<br /> is provided for information can two substances if appropriate, If tco,rle than : a ��v, asa :
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