|
f °dS *C T IONS
<br /> G'NERAL
<br /> In box titled "EMERGENCY', indicate whether° emergency response person€ei S, SOURCE/CAUSE-
<br /> and
<br /> OURCE/CA'1SEand e uipment-we,re involved at any time, If so, a Hazardous Material
<br /> Incident Report shwu,d;be filed with the'State Office of Emergency Indicate source(s) of discharge. Provide details on tank age; capacity
<br /> Service=s (OES, at 2800 Meadowyiew goad, Sacramento, GA 90832# Copies of and material if a tank is involved. Check box(es) indicating cause of
<br /> f the CES report fora. may be obta;red At your local underground yank discharge. More than one box may be checked if appropriate.
<br /> permitting agency. Indicate whether the 0ES report has beenx filed as of
<br /> the date of this report. 9m !RESOURCES AFFECTED/AT RISK
<br /> In spaceprovided, enter state tank ID nsaaher if know"
<br /> a State IJ nsambers l" section titled "RESOURCES AFFECTED" indicate whether any of the
<br /> have been assigned to all tanks that are an file with the State.Water resources listed have been affected ("YES1f)', will not be affected (€%0"),
<br /> Resources Control Board ;Enter today's date in the box' titled "Report Date"m or may be affected ("THREATENED") by the release. Check "UNKNOWN if
<br /> Enter local and Regional �ater' "ual°it Control Board case numbers if unsure of the status of a resource. Specify an unlisted resources which
<br /> 3 a' i? .r y
<br /> known. Eater the US EPA facility number i.f;applicable. are, or may be, involved under "OTHER".: The same'instructions apply to
<br /> the section titled "WATER SUPPLIES AFFECTED." Give the number of water,
<br /> 2. REPORTED BY wells affected or threatened, if known. Provide the name of the ground-
<br /> water basin underlying the site, if known;, in the;space,provided.
<br /> :eater your name, telephone number and address, Indicate which ;warty you
<br /> rrl,rt'Ser=t, and pro corspany.:.or agency name. 1.0. COMMENTS
<br /> RESPONSI Li PARTY Use this space to elaborate on Any aspects of the incident.' Comments on
<br /> " .....m.,...
<br /> cleanup work or planning or related>investigations should De reported o
<br /> Enter the nacre, telephone number, contact persons, and address- o€ the a separate Cleanup Tracking Re p6 rt.
<br /> party responsible for .the' leak, or marc unknown. ;For tank leaks`, the
<br /> responsible party would normally be the tank owner. 11® SIGNATURE
<br /> 4, SITE _OCAFION Sign the form in the space provided.
<br /> Eyster Infor:at on regarding the tank facf1sity and surrounding" area® If a DISTRIBUTION
<br /> known tank or facility i� not involved, enter general location of the
<br /> Contamination, sate as hest possible; i.e., street, city, county, zap, Hand deliver or mail copies of the form as follows.-
<br /> cross
<br /> oll€a s.-
<br /> cAross street, and type of area.
<br /> 1) Original - Local Agency, 3) Regional Water Quality
<br /> IMPLEMENTING-AGENCIES Control` Board
<br /> /Ernter names of:the local agency, Regional Board and/or Toxic Substances 2) State Water Resources 4) Toxic Substances Control
<br /> Control Division, (TSCD) regional office involved and a contact person and Control Board Division
<br /> telephone number for each. Division of Wates: Quality Underground Tank Program
<br /> Underground Tank;Program 714/744,P Street
<br /> 5, SUBSTANCES INVOLVED P. 0. Bax 100 Sacramento, CA 95814`
<br /> Sacramento, CA 95,801
<br /> Enter the CAS n�ber(s) (if knsown), name(s), and quantities lost of all 5; 0w.ner/responsible party
<br /> hazardous substd= c'e4 involved. Attach an extra sheet if more than two
<br /> 0t stances are it=Voved. Be as specific as: possible." _
<br /> f
<br /> 7. bISC€IVERY/ABATE NT°
<br /> provide iOoraiation' regarding the di=scover and "abatement a'f the
<br /> dis harge,-- Mare°than one box may be checked in the section's titled "Flaw
<br /> scovered' and "- ethod`Used To Stoll Discharge" Jf appropriate.
<br /> i
<br /> k
<br />
|