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INS TRUCTIONS
<br /> -1 P. C Leak'Bein, 'Can'firmed - leak suspected at site, but has not been confirmed,
<br /> Indica+ae whether emergency response Net 6une:l and equipment were, involved Pr`e3 iminar.> 53t.e As>essr et>t tvorkzilan Submitted - workplan/proposal
<br /> at any time. If so, a Hazardou=s Material Incident Report should be filed requester of/submitlted'by respont-lble; warty to detexrire whether ground
<br /> r
<br /> with the ,state Office of Emergency Services (0,ES) at 2880 Tleadowvsew Food. cater has been, or will be, .impacted as a result of the release.
<br /> Sacraments, CA 95832. 'Copies of the C1:n report form may be obtained at Zxeliriirary =.»tc,'1 ses5n„nt. nderwaimplementation of warkpl.an,
<br /> your lural underground storage tank permitting agency, ?ndicata WhetherI' 'L a :ri32 Characterization - responsible patty is in the process cif, fully
<br /> yurs �,.
<br /> CHS report hasbeen filed as of the date of this report-' defining the e;;ten.t of contamination in soil and ground water and assessing
<br /> ir,"apagts on surface and/or ground water.
<br /> LOCAL z.w,-"NC.Y ONLY Remediation Plan remeclla i-on Plan submitted evaluating long term-
<br /> To
<br /> erm`;°o avoid duplicate notificat on u:rsuar:c to Heelth and Safer
<br /> 11 p y cede _>cUt;.i:cn iemccaiatt.on c+iits.o:zs. Proposal. and asnplc:rnentatxcrn schedule for appropriate
<br /> 25I80.:5, a government employee should
<br /> sign and date the form in this block, remediation aMta.o:as also submitted, '
<br /> A signatrure here does u, r::eata that �<ae leak las been lei=r _isd to p>ase a Ct axicip awz ler vats implementation of remediation ice,
<br /> significant threat, to humeri bpalth or safety, 'only that notification ioh East Clean=a �si<itari. _i==o rosre s periodic a;x.aond water or other
<br /> procedures have been followesd if required,.': monitoring at Site, as necessary, to verify and/or evaluate effectiveness
<br /> ofremedial activities
<br /> REPORTED', Y Case Closed - regional board and .local agency is concurrence that no
<br /> Fllter Your name.,' tele hone number, and address indicate which o aaa ty you further work is necessary at the site.
<br /> represent and provide company or agency mane.
<br /> !MWOR.tSi'T- THE INFORMATION PROVIDED ON THIS FORM, IS INTENDED FOR GENERAL
<br /> RESPONSIBLE: PARTY STA,.ISTICAL PURPOSES ONLY AND IS NOT TO BE CONST-'P:'uEb AS ,t FRIE NNTING THE
<br /> Enter nacre, telephone number, contact person, and address of the party OFFICIAL POSITION OF ApIY GOVERNKEENTAL AGENCY
<br /> responsible for tate leak. The responsible party would normally be ;lea^~ tank
<br /> owner. : rLa�BLIA7., ACTION
<br /> Indicate which action ham=e been used to cleanup or remediato the leak,
<br /> SITE LOCATION Descriptions of onions follow-
<br /> "Enter, ” n�dra+ # � � �axdang-the k facility. At a minimrutn, you must
<br /> prays dNt acility�a en.� d full-addre s. C�Site install tsoxi:a:tel impermeable mea>oa..e layer to reduce zairafal?
<br /> .,, infiltration,
<br /> r P mil LiSi A EXvuC S''
<br /> Containment Barrie_ .x stall vertical dike to block horizontal movement of
<br /> Enter names of the local agency and PC<� cna?. Mater Quality Control. Board aontarin�ant',
<br /> .. e
<br /> involved. Esc avat i and Nis au - remove contaminated soil. and dispose ase in approved
<br /> site.
<br /> SUBSTANCE'S 7NCrtllVED Excavate and Treat - remove cont;alrinated soil. and treat (inclrides s rear,> g
<br /> Tater the name acd quantity lost of the hazaarilous cubstanc'e i.nvolv,,.,. Pvam or _and Hiring)
<br /> is provided for information on two sura. ` nc if appropriate, Tf more a Remove Free-Product remove flc.t'ng product from water table.
<br /> two substanc6 �1aakedy,-List the tea o mos couce--n for cleanup. ,a> ai M at - generally employed to rle"_ve dis�o:ved
<br /> contaminants.
<br /> DISC.tiVEP /ABA'i...s' ;' Inh a.c;erl -o .. d use of any available techllolcgy to promote
<br /> Praracie i*.f aa;nat ...t. zegarding this discovery and statement of tile a 4e 9.a1 cr ampa_ ta.st of contaminants,
<br /> Roll�a ,. providealternative tufaa"ily tr sScct
<br /> SG=3RCPTCAUt, she t aL at oox a • inst�:l InaE er t.re a„,.iont d vices at r ach w .,.:. .g or
<br /> I'nd ate soul ce:r. of Leak. Check r,.a a,e„} indica,.„ng cause of leas:.. other pi - r of use,
<br /> G 171 lct as u,,,rp or,bto draw air terougaa ci
<br /> V Sc, h w allow volatilli a:...,-..,, of.
<br /> Indicate the carr type »ategcry for ,his :leak, Check area box only,, Caar,e No az �m a wiz uc adont i, c._iuorrr.i
<br /> , recr_ng no remedial actic,,n.
<br /> type is based oii rhe most. :ensi.t-ve resource affected. ecun�,
<br /> For -
<br /> -, if
<br /> For �
<br /> both so - and Szo-nid mates have been affected, case type will be "Crr nd, Cdrl EN'Ts Use this s ace, to eLal o.ra e on any aspects of the it identa.
<br /> Water`s Indicate Drinking Vater' ciails f one or more rr.z>r. cipal on;
<br /> domestic water wells have actually been i ;:ct;ed. A "Ground Water„ nl.p,,TTJ ,W'ign the form in the spare provided,
<br /> designation aloes, not imply that ths, affected water cannot be or is nor.
<br /> used for drinking water, but, only It at xa.cr wells have that yet been DI>'TPTBt ION
<br /> affect,ed, it is understood that case, type, may charge upon further If il.e folTris corcpreted by the tank ccvnor at his agent, wat...,is the I.:.:,...t copy
<br /> investigation, ? 'drward the rercainirg copies intact to your loom tank per:..r -in; lig ncy°
<br /> _o- di st ribu,Jon.
<br /> UP art STA
<br /> THS€`” I. Original al t.a;. Tank r u:rmit,t ,,, Agency
<br /> In% car;e? .l_e categ which best describes :.a current stalbus of �€,.ere, case, r_, Stl,rt- Wain esources Ctsnt of Board, dxsisio, of C.1eaan Wate; a"I' _
<br /> l:lar, n bc,,x ren v t,br ,.c sponse Sho%i?d be ' lative to the case t.,re. o r pa;cl z Storage tank Program_ c "_ aa.,..... 44_
<br /> e
<br /> yr r,,ie. if c,_,ia �..kou,z.z rfawt..r`, tle.a Status- ,alb>,�:-d -.,fer 220
<br /> to tile statl,15c qve ground water'i=,vesitigal-1 n, or cleano_ , :_ ops aced to weg.os �rWater tt '_t
<br /> r,uaAd
<br /> cz s .; r r Awa una of +, f 1 4 Health v ax aea uy Board f rye .i.,�a_>, t xs,_ c
<br /> recelve Prapas tori cd aw t ,.rxs.
<br /> Do Lien rtk ra - No a-tion aaas b,en :arae by responsible party bey-pn'C" a- vlrct?,, .tv-
<br /> r,t,I . .pot xsi =.n.>..:.
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