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iNSTRUCTIONS
<br /> tIME PGKtdOY Leak yoL Co f r..;t,_.i -- Leak s. s reeled a,, site, bur, has not been confirmed.
<br /> Indicate whet1ner emergency responiie pez::,)nnel and equipment were involve h':9 .im:i:za: } w, -n t, aE ax _r.._ tt l l was r`pr. pc;ai
<br /> at r..rab t%e, If sc, a Hazardous tla€er al incident Report should be filed, requested of/ ab it d l.v z. nsi c .q ty to d t�.,, ine whether ground
<br /> State the � are Office of Emergency Say�>s .es (OES) at 2800 t each.w;ser ,
<br /> ,�..R a orate: has been> or williimpacted a .>r._:
<br /> _�a _ ?t: of the release,
<br /> Sacrament , A _5831 Copies of the DES report Arm may to obtained at. P lim n . r r,.a Axa � implementation r workplan,youri- l :a_,a.argro-�a�d storage tank peric tieing agency, .--ndi.c&te , .;..the- Pollution ,y,r c _N}o r.3. ... party is in ..�e: process of faa7..iy
<br /> z
<br /> the CES _eh. -t has x m :pied as of Me date of s,azs ru?o,L, defining the Rr.,..Eet of u.r,..taa- z_at3.o., in soil ark ground urat:.e and assessing
<br /> impict u.3 surfa a .., t/or growd wa ax,
<br /> To avoAd dniHarte nwifisation purn,-
<br /> to health and Safety amu.. Sea _.on rasMdiat-on optr ,ionr, Pr i ..,aa. an ar�3,�,. .t,a<.._w„ _cher<o..e for appropriate
<br /> 22i 3L, M, a gov_, anti x r.up,loyee should
<br /> x
<br /> _ sign
<br /> at, date the farm in . _n a.,cckremediation option ..'sr submitted,
<br /> A -f attire e _ n n .aci that the leak lies des-, determined "n, pose a Cleynn, lz_ E: wimimentatorl
<br /> of .eedia io plan,
<br /> significant, .tr a t.a f_ ,,ava health .a safety,eiy, n t that ouz€ ;, .wr st lc r . to a i. e:ss re .o3_ -sl water or
<br /> pr„ce,._�i,_ have besn foo-nr.ud if xequired, monitoring at si e, s necessary, to era,fi m.€./ evaluate tet ,enr.ss
<br /> of remedial e rav't'l-s:
<br /> -' T1�_ e Case ii t ea - lahmal board and local al .gency in we rence that Sao
<br /> 'amok nter n, teleducac number, and address, Indicate woic p _,t ,,a further wort is necessary at the site,
<br /> h r., v-d prcvidr sv.; y or _der,cy name,
<br /> Itd?OF:TANT: 1`12 INFOrMa' ON PROVIDED ON z.;:iS sMM IS iNTE DED FOR GERERM,
<br /> r
<br />' P st, ._.._, STATISTICAL aE_RPti,4F.S OiCua t.,vh, IS NOT TO BE CONSTRUED ky Ra-:,bTESFN11 !,.5:
<br /> Edina, namo, ....n e nu:aEben cormact, person, and ad:dre,,. -f the party OF"FICIAL, POSITION OF dNY
<br /> ospax.,.,I,',o +
<br /> x wht, leak, The re,paz.stSale party wn,la:'€ .olaral !,,,a t.Re ms:
<br /> oWne:c. t T TA7, A 1SCiR
<br /> Indicare whichaction v wen used to ci_<uip or rcfneda_ s the
<br /> T L,CACI _ asc._.pt§orb oh erLe. a s.f _ _a,w:
<br /> ar informat ion regarding the tank facility. At 2 minimum, you moist
<br /> _>rovi.do the facility rare and full address, QM,jj c a unstall botizontal impetr._arlo laycr to r,-,,(,h;cG r,ainfa;l.
<br /> infi itI ion,
<br /> Cont wjn e-ar £ icr i.t.m-taTi taehti.aal d:.�..e. tni Lua.x..N_eta., ,,,,1_.m.w," of
<br /> ,a€,. xr and Regional Wats- QgzalNfs CoaaF,_vl a contaminant,
<br /> ._nL ls,<-d, [ �, __ c t,- ? _0zaovve. carat .ailia:;e, soil an .. -uv ;.ti tyu ,S,G
<br /> cat. Tt 7_ _,_..i:, n�n���>„ ,�..,�� U ,A.0 �.rz-� „N�U ,_.tit�.a
<br /> u eg
<br /> Enter the ,ame and�quantity Lost of the Laza welds� ,,,r,,t a ,_ _, tel. __.. or A_ , Qn,zn
<br /> is promded for anDsr-nation or, two substances if afl-oati"n,; , z
<br /> two substances leaked, list the two of most concern for ,...e._ve _ . F g ne,< l ,, _;.:;-f.a , to r..,,,ve
<br /> x < 3 $
<br /> r r � Quzm,bim regardii,. the ascovezy aE.;3 abatemnt, c f the leak, 7,,., _. ,.a;r, .r:_.. .,L <<
<br /> o
<br /> S
<br /> Cann el
<br /> u or _ W"r
<br /> ,
<br /> b.
<br /> VETO L. t for this leak, Clmck one box only. U, is moncy, re"Kha in "Mesa! arNon,
<br />,
<br /> �y
<br /> re ,,... -, e s . n;U w v���._ti.va r� o�_c,� ,C:Lvc;pd. P,��: eraU, ,
<br /> t 4
<br /> x so , a - �, ater noon; been a 'aM , case type �mm` r. PENTS Use q> v eto e0borle as
<br /> ar e - incident,
<br /> Water". llolicaLv _inks g WW-- only it one or more mmUcipai_ or
<br /> �,.
<br /> cxo xa:._.,,, ,; , .ic ha � ava ,. ,:ua>_z�> been affected. A 'Ground 6�ai;k>r i '
<br /> _.� � LTRZ. _ ° ,.i i�_ .�,_,,. the araos provided,
<br /> � ect.
<br /> designation does a,., imply that the affected water cannot be, or is no ,
<br /> t
<br /> c1seo for i.-ink . r soner, but _i.;y ilaa`, water wells have �rct yet r.ea �� i I I
<br /> x,
<br /> affeand. it 1z unTu_t,ct that case type may change upon f ru_w r if the form .is compiled by the Luck o_ ,_ his agent, xa: aixa ,lie a�,wt copy
<br /> n „r t i g a t i aal and i rwwr> Ue rataini ng colnies inter to y"a; Imal tatty pwnittog aMocy
<br /> f
<br /> die r i r,t;i,n
<br /> CMIYT YQnV 1. Original Local Tan:,. ,mi,.t ng Ag n,,-y
<br /> indicate Ae a Lagor, Mich best describes ibes the current staters of the c,se, 2. State, K"er Re u.rc s Control. Board, ,. inion of C can Water
<br /> Chwk cane `soca only. The-;rerspon:se ske.s3.ld be relative. to He case "e, For axa_lergzri„:nd Str,,igen Twnik PrJ€F rwi, i,C. Sea, 94422.2, >. r.ea, CA 9L.244
<br /> example, If r Se t"e is .t.,. Water”, ;herd "C,.zm= Status” should zefer 212
<br /> to the status of the gran red water investigation
<br /> in,.est g.a.. ion or clearrap, as o pos ed to
<br /> wegien .J.. lW. aterQuaff , a.f r,r Board
<br /> Wlaat 4f R,sr-xrr-ons or options .oIoB = uoMBiIviFYJ. Kieand County aafjS
<br /> u of y . ._ tc „wwt ,
<br /> isrto
<br /> receive Fmposition 65 .,vf,:i__c tao_, .
<br /> No 3 .M Tiet. - No,ar.,..,... has be-..... taken by iesnnsibl.e party ;.>cym=.d -.., .a.rcrezttu,.,_.a;_ I._.; party,
<br /> initial leak,
<br />
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