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I%STFtC
<br />EMMEN a
<br />indicate �whet?er emergency response pe`rsounel and equipment were involved
<br />at any time, If so, a fiaza.rdous Naw_ri:el _.cede t Report should be filed
<br />LL
<br />with the State Office o,.:. E;norgency Services (OES) a'', 2800 Meadovr,iszw Road,
<br />Sacramento, CA 95832, Copies of the G S report form may he obtained at
<br />your locao;undergvr)und storage tank permitting agency. Indicate whether
<br />the CES report has been filed as of the W-e of this repo):*
<br />LOCAL AGENCY G ILY
<br />To avoid dup lcate notifi'ca ion pursuant to health and Safety ccs_ Sectlon
<br />25180,5, a govcrn:rezt employee should sign and date the form in this bloocx,
<br />A signature hero, dries not mean that the leak has been determined tc rose a
<br />significant threat, to huzaan health or safe y, only that notification
<br />procedures have been followed if required.
<br />REPORTED BY
<br />Enter your name, telephone number, and address, Indicate, a'r.ich nasty you
<br />AM -present and provide company or agency naive,
<br />EuPC-NLIB :E !�Ap_ t
<br />Enter mama, telephone numzrer, comae t person, and address of the na?t?:
<br />responsible for the leak. The responsible party would raczc<ally be the tank
<br />Omer
<br />SITE kggATIOPI
<br />Enter information regarding the tank facility. At a mir=imum, you :mast
<br />provide the facility name and fell address.
<br />IMPLE . i :I O AGENCIES
<br />Enter n es of the .local agency nd .e,rcntl roves Quality Conr;roL Bcard
<br />invoIved.
<br />SUBSTANCES INVOLVED
<br />Enter the nwne 'and quantity lost of the hazardous substance snv>olved, Rcom
<br />is provided for information an two substances if :p orate. T. c.:_. ;w r,<;n
<br />two substances leaked, List the two of most concern for cloanur,.
<br />DISCMIERYMBATEMENT
<br />Provide rn nrn:a . csi__re ard$r_g the d.` sc rovezy- and aba„ ..,.cn of the _ _a.k l
<br />Sd313PCF�eisj
<br />1WS—E,
<br />cate 5 urce,S} of leak. Check box(es) i2 3t >, n,a.z l.;
<br />TYRE
<br />Indicate the case Lypa category for. thisCheck
<br />.o b ._.. only, `
<br />type is based on the most sensitive
<br />resource _.f. e .,.
<br />both sial and ground water have been asset:ted, case °gyve a .. be G_ouz. ,d
<br />Water". ndzaa e `ier.,iiainp vo'te'r" on'y if one or .. _e :r._..__,r.. _ or
<br />domestic water wells have; actually,lyeen affecatee. _. G-oun-. std --I"
<br />iResagaaatinn lees rot, M
<br />qAy that, the affected water .-ani:ot, he, , is not,
<br />used for drin`ng wate_.. hot only :;haz, water wells . aa„, yet ..__.x,
<br />;affects d, _ It IS und,er vaaod t", car ,l
<br />ti
<br />status rf
<br />k one rl h ,F, a i t$:)L
<br />C
<br />t t typej to I -
<br />ti a
<br />Zst-,-tns E' ! T IIS f a i
<br />kvcf soie .,x}... ..
<br />_ or TNku acti:11,11,?. .a by . 1,
<br />%a:Sc Se3ng Cot=f,., sled - Leak suspected at slito, tract has not been cceaw ra':,wd.
<br />'Pre.Lim--nary Site As=sessment Workrlasn.ar :i? ? edl -- woxkplazwproposal
<br />requested offs bm..ttea by respon ible parry to deta..mine w_ other gro,"And
<br />water has been, or will be, inracted as a rrsala: of he rJjecse,'
<br />Preliminary Site A rcn," derway implemontation � Y kpar
<br />PO_lution Chr^_ra ..er za� _on - re p ns•b:.e party _z3 in th.e ^ro�e:,s - f fa7.iy
<br />defining the extent of contamination in , _.il and g -round = two_r anvi
<br />i� pacts on v ra"ace and/or gra;; t „xaa�e
<br />Re
<br />mea''It en -.1.en - remed ;tion plan subm t ed eva'_=uat;.kg .long tann
<br />, nedbati;. rp ions. Proposal and i.. plei-nentati on sCho ulp 701appzofr�_c_
<br />mused aticn optacns submitted.
<br />- i qple.entat ion of _z ze d_ at,' mn. plan.
<br />Fc� uiear_.mooi r�rirr in = ev„ _er;oche grou nd ;,rate- or ,rt,
<br />moni4as rg a ,_tea,s necessary, to x rif',, sand/or evaluct, > e`f"ec; iveness
<br />o= remedial actzi,,]as.
<br />t"ase `;losed regional board and loca _ z4 .;nc c.on-.u_rrenc e. --hat no
<br />further work is necessary at the .=,_. o,
<br />IM70i"'TANT: THE INFO-UMATTON PROVIDED ON , F N'�I IS INTENDED FOR Nb RIM,
<br />TISTTC Z K'v ES O ✓ ANT; N ..,Pere
<br />TO Ds i�JE.D . S REFREIS.EINTINO E
<br />OFFICIAL POSIz_c.SaY OF ANY GOVERNMENT AGI°,:.,_.'
<br />.Rrk',.7,11AL AC':IOi.
<br />to � :ate which action have keen used wu a._eouj p o me.: <at:. _.w lcak.
<br />Descriptions of o� cors follow
<br />_Car,Site - instar.: horizontal imperc;ae .re layar to rtd.ace rainfall
<br />wiz<tration.
<br />Cnts�nment Barrier -- irstali vertical cike Lo block horaz_-rital cn.ov ien. of
<br />c.on .axrninant,
<br />lx;ra.'at3 and :i-.22-�;a ..- rresl ave ,.onto Inas.--- d soil and .hj.spo . app.ro,,,re;a
<br />Site.
<br />E _ ;
<br />�r.ra <au � ars; r, -e _at - rE.n-see corttamr;aata., sail and t� ..r.; L tit ? a.xe:„ .y.reir:.,.;:>�",
<br />or lad farming
<br />Remove Free pnoduct remo c, floatingL _o_"u uia water .zbl.>.
<br />P �� �psmt._ Air waT.r ., gene;r
<br />all rlcyac tr^ _4_mo,,xc,wdisso;. ed
<br />to„t m yast4 of any a. _.. alas .,,,,
<br />a s.z.� r' z fi, �..._..,,.ngy to rro;;rcae
<br />dr�ri=. 1 corpositlon of contamina:rts
<br />Rrace l.i s, .._. _l er:_a.ive I it' _ .> pv:y to affected par`>les.
<br />atme-t _d k'u'o - Insvv_,_ water t_,�. ,..,nv ..e,.ces a-, cac: dwelling
<br />s 1 .
<br />Vacuari tr , u ,ata. t rs to d.raw air Ml,, rough soJi,
<br />`i.rea incident _,, zr,,a„r, _a. o _Exna.- al acy_.,a .
<br />9 4 Use thJ � pace to ela o_a e, on any as _ tats
<br />_ NIIN._ _ _ Z' g e 'form i_2 space pro .icled. -
<br />.
<br />n,_; fr�< 1 �. '.`.kt „_sea _z, �°.: �., cop
<br />_.:,..: v.Ft: �.'., tc, vcur
<br />"a”, _.<..,t I _
<br />_.._,.d, .,<,..._., .> atrr
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