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INSTRUCT IONS
<br />EMERGENCY „
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<br />L �k *dei. Cort',rYncd Lea suspected at site; but has not, beer. rn_irmcd.
<br />Ln{3iCate what her omier end e
<br />g' 'y.. ,.._ petSvq personnel ... 3Y}� g:�a;."..�3aTiEru W�'a'8 '.7S3rG..L'8£'�f%
<br />�i"2? 10E:..;11r v3t� c�i58 iilfz%SL fi'a.:k lari JLtk>ITt4.tt.•.•, s;,. Wii k p3.. uilj a"3=`Jpti5 $),,
<br />at any timetLLf so, a Hazardous Material, I,nc ant Report s�iould de filed
<br />requested of/submitted y responsible party to determine w_etizer,gzound
<br />Wk t}Y the? rix :ateeJfi'm GP C,. ;nC:,x',, 4siYCV J i'i::.✓5 (OES) at, Z8Q0 Mea ow,,i�w -Road,
<br />wa ,firr'nas been, Or "v,"S.11, be, iRii:a^wtEd a5 e2 result of the release,
<br />$aC.r:a%yS'li.nti , `GA `;,".38832. Caries of ti+e CES r, sport form may be, obtained at.�'" ,.
<br />Pre i i `ir'Y Site Assess nend'y 3deX'way '" implementation of i^Yorkp.�-ca .
<br />yourds"S£aa. UY:d2r .YWC3tY d storage tan.?", CrP.;itti::g.. ,P-�2x:uy,:-. .: II'.ElkCate whether
<br />Pollution � -rade �Gr3 recporis.t,Gl E Party l.S in the .)rocess',of fully
<br />the :Cll•,S A"{«'6"°w I1a5 i3:e C.,.. ii`f.ed: a5 4f. the datc 3f :..175 repGrL
<br />_- ., defining ttie extend`. 'G°s. Ci71:t+aiYY,;.natia it SCa.,a. ..,i.,: �,_G<,,P,-..,� water ?Ya=.� aSSBss'i=�'
<br />Impacts on surface avid oz Fy%.'o+;nd: water:
<br />LOCAL AGENCY G`hY,
<br />Fcmedrt;i <en v].ar - reaYf latiGn plan submit kc: eva'LxY �<1 .; term
<br />To avoid dup le�ate'notificat;on pus.,uant to Health and,$afety co ie Lee. G#i.
<br />remeditxtkon n, ans. Proposal ax?d Implementation schedule for appropriate
<br />2S1 f3. a govefn;pent employee should Sign ane data theform in this bloc:L....
<br />ae'11E'ri3.e$'�.LC,Y (3pt.1U'`S1S also submitted,
<br />A signature heA does not mean that the Leat has' been determined to pose a
<br />CleaaY€ t:nderwav -- implementation of remediat; or; plan,
<br />significant treat to human health or safety, ^sky that nctffi atlon
<br />Pot Cleanup Monitor,:g in eraLress - periodic &round water or other
<br />procedures have been fcil.3.0'rr"ed 7.f xe
<br />M011i'tO ing, at Site, as necessary, to verify and/or evaluate effectiveness
<br />of remedial activities,
<br />REPORiED-EY
<br />lase Closed - regional board and local agency in concurrence that no
<br />Enter your name, telephone nlwnbe. ,' and address. ' .indicate which party you
<br />`urther want is necessary y at- the Site.
<br />llftprese-nt and provide company or agency name.,
<br />'
<br />IMPCRTANT, THE !NFPITMATION PRGvit3LE ON THIS FOILM IS INTENDED FOR GENERAL
<br />ESP XSIBLE PAUY�
<br />fi IJ. W PURPOSES P0^aE1 i3 r4.,i AND I NOT TO B11 CONSTME AS REPRESENTING -THE ,
<br />Enter name, telephone quirber, contact person, and address of the party
<br />OFF MAL POSIT -ON Or ANY GOVERNMENTAL AGENCY
<br />resporasab e for the eak. The responsible party would:nozmaliy bs the tan
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<br />owner.
<br />REMEDIAL ACTION
<br />Indicate which action have been used "a cleanup or reradiate the 'Leak.
<br />SITE L0CATTgN x..
<br />ions of op
<br />ptLions follow.
<br />Enter itxforwation regarding the tank facility. At a minima..,, you must,
<br />. <.�
<br />r
<br />provide tie facility name and full` address,
<br />Lada Sine _ install horizontal impermeable layer to reduce rainfall
<br />infiltration.
<br />s
<br />IMPLEMENTING AGENCIES
<br />Co tai:nmesit £sarr4 er - nstall ✓erulical dike to block horizontal t:oveYnent, of
<br />Enter names of the local agency and 'Regional t€ate� Quality Control. Board .:-
<br />c,.nta"I"nant.
<br />7nvol.ved.
<br />Excava remove contamunated soiland dispose .1 app -ra-
<br />ved
<br />SUBSTANCES l3
<br />Eac Tauri and Treat - remove contaminated sfx l and t_,at '( Y cl.f.:e's , prea,,.«., ,
<br />falter tLe namef and aUav_tity lost of the hazar. pus •substarxe 1yni.Qd. Ra%
<br />or lard farrirg).
<br />i . r r
<br />s provided for i, fCSrSYiat'ion can°tF7G .substances if appropriate,' I moo -re ,:ia-Y
<br />:..
<br />RrrrGve Free I'rocit"ct: - rerno'=re floating product from water +.u..sl.e. '
<br />two substances leaked, list' the two of zrnost concern for cleanup,
<br />P mn and Tr,.at Groundwater -- g_n —r. lly empboyed t; _amove di-, soured
<br />DISCOVERVABAT� x1 N"
<br />l ncod ;s ode r idai ion .zse c>f any available tec faxlogy to prom e, %
<br />Provide in_o-mint.on,zey ardlL"�c, the disci verb` end 'abatement of 1, c. .-e al: <
<br />bactexia. decomposition of co,txrdi:narits,
<br />provide alternative tk ter supply to ' ffe£ d bar 'sus •
<br />cia?GEICAt,Su
<br />"eat,meY_t, a., oukup -- i�fsta'I wa:ez.' txeatnaent devices at cae.. dwelling ,
<br />Ydicate sou:crQa) of lees. Check box(es) -ndicat-mg cause of leap
<br />other placc a' use,
<br />a t .,n Fxr t us � arsps or h orrery G draw air through sol_
<br />�EYYPE
<br />1, Ci miasma holes ?." Z '3_ T .. G>+r .'. 31..i .�Za .<On O:E i^ minants,'.
<br />o allow r La
<br />Indicate the Cd @ t5 pe category :'a this. leak . Cc. _ck one bqx GYil::,. C: ast_ ,
<br />E,, .i' - Ld.re f " inc :.deli`. Wu m or, t -r its_ _i..g no remeo_ 0, action,
<br />type is based data the .most sensitive resource a ffe:-cod. For exa,znp
<br />both sol: and V.caund nater hx,7c been affected, case type will- be G_t✓u1:1i
<br />=MFN'_S- _ Use this space to elabc::ate on any aspects of the _nc.dant,
<br />Water" indicate DrIf king rater" only if cne. or Dort' mt.iciy?al c --
<br />domestic water wells have actually been affeC Hd. : A -Ground, Water"
<br />:3lGNA_MRE " Sign t e foral in the :il,'.•ace provided,
<br />' denigration does %aGt. 3S'i;,i.j' that the affected zn er cannot be, of is aG
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<br />L'l �aq�?wd for drinking water, but only r,.Y i,.. water wells
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<br />affected, Tt understood _ids.: :_ase type -may change upon fortb:er
<br />vDISTRIBUTION
<br />y 1
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<br />..i..f i.Ii�': form C: f�zE:t..l. eted y ti:6. ��Y..+.l' l',1'f:eS 3°,.r <.B agent .C. :.,n e l$$: ^.Gi;y
<br />n ess,igation,
<br />na ru vc. tf.d .ra; aims- conies nv < to ,:our local t _, � permitting agency
<br />fort s c
<br />-.�- ---v
<br />ind cat he � ,
<br /><. the C �Y... {, :7�f which Psir,' L' .. esCif .a ;2v 5t 31 Fi of e 2 G,,.
<br />1. It.L n''a t. .uL7 Cr?£3. `-C !'. Cl , ,.._ir'n "",. <_„ Water :->VZ11
<br />(. C:"u's•>k CtiiE? box on ly , 'The response 5h_Sal r, t, i...l-", 7x to ,.- .;2:sl,a"-:U
<br />c E
<br />?E'_<.. ui_d Stern2 Tank r.. .. -. t„C :”? ..1. L;. '.r,.:., , i L tti?,
<br />type (rr i^is > L `. .:i i refer
<br />tD thestatus' Ca " gx C -.,..;d wate 3l Ml.ean .r
<br />m, ., -ts op', >_-ed ,.,J "
<br />R un..
<br />g"., 'Wat, Qu_,..?,i {.,C.t.
<br />«+�o'
<br />t.b,"t Of zoi_: _;.,i„n+, c. :z,.•.-.*'. �
<br />4.Local %d'59;ir.aa and L:-.� F� ._3T_....t."., ,,.... .:. ., _a<.. v'' n., ._C t. u
<br />i__ .. faken :: wi ac ti on Ya,.:a, i t. ai, t ax '1 iii
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