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IN STRUCTI.O';
<br /> °tdEF£C E CY Loam Bei7; - Leak suspected at sive; but has not been confirmed.
<br /> Indicate whether emergency pe-rsonnel and eq�uil neat were involvedore' it ary G .te r..>se 5n..,n bra—kuLar Subm2.tt d --,ws k .z.an/croposa
<br /> At any time, so;. a Hazardous Material ncident Report, should r,x° filen requested of by responsible party to deteranine Whether ground
<br /> with tl e Statetttf_ce o, -ksnc,,
<br /> gency Services i0ES3 a:. 2800 P?aizdowssew Road, water has been, or'will .:>e, 'impacted a= a result of' the rebase_
<br /> Sacramento, CA 1-5532. Conies of t,.t.e GES report..form may be obtaw„ed at P e ._
<br /> .liminary Site Assessiiiont ..:der av -. implementation of =aokPLar..
<br /> your lora: underground wt-. gage tank peraitti^g agency, indicate Whether11.x:t,a�Cl.ar .,t ediza}_c reeponsible party =s in he process, of filly
<br /> ,i.e OES _e;rc.:I has be�,,nz filed a- of the :bate of this repot, defizai g the extent cf con'cmia,ation is. soil and µ-roam water and assessing
<br /> i:nlzacts on surface ::Ind/ox ground water.,
<br /> LOCAL AGENCY ONLY
<br /> C 3i .1�n - res€e i ion pl_an , i�: d QvalvatLng long term
<br /> To avail dna_^,L rate roof caciozz pursuant to Health and,Safety code ec`,icai .emediatzon options: - Pro-,coal <at?d a , .,K _..ata rxa - ?zc s?.e ,. pI ar;ria s
<br /> 2541Ua,5, a government employee should sign and 1—te the-§o m in this llrel. rc e.. a c£a ptI ash su}xn: Gene:.
<br /> A signature here dies not mean that the leak as been determined to rase a C�aaat dt,,rwav inplemeritat on of:remediation plan,
<br /> significant ;:areae to E_wmin nealth or safe v, on' that notification' Pas rl_,as.<> 'Sc.aitori'_,. ixa :mss periodic g?oun l wr=t._ ons o s-
<br /> procedures have nen: fcaUnwed if r quem:.d. i tr., at '_ten <i ..ere: ary, t ezti y and/u,' evaluate e fecti.veness
<br /> of remedial acti^rit=es_
<br /> REPORTED BY Case l ,
<br /> �� egsenaw.'::care and Local ace:,ay to e^ar;:.at,•xer,ce wixat, no
<br /> Enter your n;L e, telephone number,,- and Address. IndieaLe rich party you further woaric is necessary,at the site,
<br /> present
<br /> t and prcvide company or agency name. ”
<br /> IMZGr Ada: THE IFJl7ATI0 PRCa s LD JPS HIS FOIR M IS INTENDED FOR C.'VLF AUT,
<br /> WIESPONSTBLE rTrR Y SICA ISTIC L _ 'RPOSES 04LY AN 1S NOT TO BE CONSTRUED AS F1FRESENi'INC u
<br /> Easter name, telephone number, contact person, and:address of the party :)"r'FSCIAL POSITION OF ANY .,OJERNM..t,xTA.L AGENCY
<br /> respors%ble for the _calx. The responsible party would normally be the tank
<br /> owner, REMEDIAL ACTION
<br /> Ttidicate which action have been used co cleanup or remediate"the leak.
<br /> -SITE,1f3uAT ON Descriptions of options follow:
<br /> Enter informal'ion regarding the sank Facility. .At a minim,,-n, you icust
<br /> provide the facility name and full' address, uu % e - inst'n, horizontal ialper�lieabllo'Layer to reduce rainfall
<br /> inlil.tration.
<br /> IMPLEMENTING AGENCIES O� t<�i�m cot Lazo:.r r - install vc.ct.i cal dike to block horizontal movement of
<br /> Enter names of the .ocalagency and Regional 'via}tee Quality Control hoard contaminant.
<br /> involved, i:xcavate aird Dispose remove contai:zinated soil and d=ispose in approved
<br /> Site,
<br /> SUB7 lTAPIgl'u TNVOLVED Eycavate and Treat remove contaminated soil and treat s(includes spreading:,
<br /> Enter the nave and iruantity Lost oX the hazardous substance' :r.rvolved. Rona orlaid fat.rnix,,g},
<br /> is Provided fox information oil two substances if appropriate. If more than Remove Free Product remove .,_loati,ng product from water table.
<br /> two substances leaked, list the two of mort concern fes.:'cleanup, Puma and Treat Groundwwalor , gener.a:lly employed to remove disso=lved
<br /> UIS::€VERYlAJATEM?tT nha.ce d Biol'e ratation use of any available technology to promote
<br /> Provide _n`'oi:-r.ats,oa .regardiru the"dJscovery and Abatement of the lack. bacteria' decomposition ot, 4p.ternI-nants.
<br /> Iia rte ,' provide alternative water supply t Affect ed parties,
<br /> e tt rzer L a ookun - install waw.xr t.eatmenL devices at:each dwelling or
<br /> Indicate source',$) of. Leak., Check box(as) indicating cause of leak. o r� lirt a e of e. '
<br /> titan Ext act use pumps or blowers to draw air through soil.,
<br /> SE TYPE Vert ,ov - bOre holes in sail to allow volatilization of conLam_narts.
<br /> Iz'rdicate the case type category for this lea. .. Check came box only. Case No Ac,tkzcti z<e it red - incident _s minor, requi_int, no remedial acL i on,
<br /> type is based on the most sensitive resource gffec'.ed. ''For example, if
<br /> both soil and ground wa'er bAve been affected, case type* will be :due:Cz CfX ENiS - Ilse this space to elabo-rate, on any aspects of the inc.ieent.
<br /> Water" Indicate "Dri'riking Water only if one or more municipal or
<br /> domestic water wells have actually been affected. A "Ground Water" SIGNATURE - E n the fora in the''space provided.,
<br /> designation does not, innj,y that the affected water cannot bit, or 4a net,
<br /> used for drinking water, bort only-that warner wells have not yet been DISTRIBUTION
<br /> affected. It is understood that ease type may chat<ge upon further if the team completed by thew.;k owner or rets agent, retain ,cae`._a copy
<br /> Lnvestiga-ion, and forward the remaacz._ng cop,.es intactto your _>ua:w tank paacaxtt,:.=lag au.yn^,
<br /> for' «S,triixcz.,:
<br /> CtPUR x,t TxS ,; Original. Local Taink Perm:ttin& Agency
<br /> Indicate the category which best describes the current stature of the case, 2, wa_, ; Ise-sources Control Board, Divicia;n of C:;eai: Water Prcg rai,,
<br /> Check bane bon: only., he resY.onse should be relative to the case type. For rJnderg oda_: Storage Tank ci tea P;O. Fox 44212Sacramento,, _ CA 9k244
<br /> ex .neon 'C:�icxrt. StatP'u;":uho"Aa,a rcw=ar 21�.,
<br /> ' txaxtiil.r; at. ,.a.e type is `Ground, stdrt�r . �. '�a "
<br /> to the L at,zzs'of tlle ground water dnvestlgatiod or 3.eazicsr>. as, opposed to 3 Region?L W'ater QuLl.ity Control Board
<br /> ttg at orf soil, Desc.s ons of op.,,"con„ follow Local "r.`...;,a_ Off fez• and Caunt.y Board o ur ,. I, lgnee ,
<br /> t opo _r. Lf-, .s.,9.i. c atd craw
<br /> NN,i Action, [ .,' No act.ioor; has beein taken by res,o ,,_.tl_t, p a�—y be ,,.+{ `_,_.., :. ,1,_ z,a<zt,y,
<br /> of ","AK," ,'.
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