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us"kG&INCY
<br />indic"e Metber emergmicy response personnel and equipmut were involved
<br />at any time. If so, a h,'-.'Z,,.EdQ-us Material Report should be filed
<br />With t' a State Office of anna
<br />ely Services (01ES) at 2600 11padowview Road,
<br />Sacramento, CA 95832. Copies of the DES report f=m may be obtained at
<br />your local. .-Inderground Storage tank pLrmitting agency. Indicate whether
<br />the DES report has bom filed as of the date of this report.
<br />1VML MOKL 010"r
<br />To ovoid. dupi-icate noti-ricza-ion pur��uant to HeaLth and Safety code Section
<br />25 1 PD . 5 ; a g bent: wiployee shmUd Sign and date the form in this block.
<br />A Signature here
<br />.t mtan triat the leak has beer determined to pose a
<br />s3.g.ndficant threat try 1;e"IP-,11 or safety, only that notification
<br />have hjun fol.lowc,3 if required.
<br />REF( ;VD) BY
<br />Enter Your name, and address. indicate which party you
<br />—Mesmt and Pnwhk cmpmy or a"ncy nwm,
<br />Enter name, tel-p2�,,onta:t pei:son, and address of the party
<br />respousibLe for Ma leak, The res-ocanziole par --y would normally be the tank
<br />SlTTIE 120MARTGN
<br />Enter irformatic'.1 rogardiuZ, !,`.h,e tank facility. At a minimum, you must
<br />provide the nzme and full address.
<br />E: tet: n<jmres AGENCIES,
<br />of tj�,� iocal. ag rd
<br />,cn,zy and Re -gional Water Quality Control Boa
<br />Emut We name and quantity lost of the hazardous substance involved. Room
<br />is provided for informaLior or two substances if appropriate.
<br />If more than
<br />two substances leaked, List the two of iiiost concern for cleanup.
<br />LII: uVFiYrABATt':'uN"C'
<br />Provide information regar3mg the discovery and abatement of the leak.
<br />Indi.cate source(;3) of c
<br />Ch
<br />, -ck boxees) indicating cause of leak,
<br />cot 7_'PE
<br />indicate the case type category for this jeak. Check one box only. Case
<br />type in based on the mwt sensitive resource affected. For example, if
<br />both ::oil and ground water have been affected, case type wil-l- be "Ground
<br />Water". Indicate ":Drinking Misr" only if one or more municipal or
<br />domestic water wells have actually been affected, A ground Water"
<br />designation does not impLy that tnxe affected water cannot be, or is not,
<br />used for drinking water, but only that water wells have not yet been
<br />affected. It is understood that case type may charge upon further
<br />investigation,
<br />C.q.7 !TA'VZ-TS
<br />Indicate the category Mich beat describes the current status of the case.
<br />Check one box only. The response Should La relative to the case type. For
<br />exampLe, if case! type is "Gromd Wmer", then "Current Status" Should refer
<br />to the status of the ground water investigation or cleanup, as opposed to
<br />that of SUL of options follow-:
<br />No MAice Tak"a - No aww& has been taken by responsible party beyond
<br />ini-tial repor.t of
<br />LMY,Being Confirmed - Leak suspected at site, but has not been confirmed.
<br />jyUminmy Site Assessment :Workplan Submittec[ - wo.r.kpl-an/proposal
<br />requested of/submitted by rerporisible party to determine whether ground
<br />water bas been, or will. be, impacted as a result of the release.
<br />prelim�inary Site Assessment Underway - implementation of workplan.
<br />flo,lloution Chfarac ter izat, on - responsib-lepazty if -,in the process of fully
<br />defin"; the extent of taminanon In Soil and ground -water and assessing
<br />impacts on surface 1'.n::/ or g�,:otlnd watel.
<br />Remediation -Plan - remediation plan sub-.T.Iittad evaluating long term
<br />remediation opticus. Proposal- and impl.3mcnta--ion schedule for. appropriate
<br />e 'd.iatio
<br />n options also submitted.
<br />Cleanup UhMny, - implementation of remediation plan.
<br />Post Cleanup t4onitorin& in Progress - periodic ground water or other
<br />monitoring at site, as necessary, to verify and/or evaluate effectiveness
<br />of remedial activities,
<br />Case Closed - regional board and local. agency -in concurrence that no
<br />further work is necessary at the site,
<br />iMFORTANT: THE YFORFATION PROVIDED ON THIS FORM IS INTEMED FOR GENERAL
<br />STATISTICA-T. PIJ.R;,:'OSES ONLY AND IS NOT TO BE CONSTRUED AS REPRESENTING THE
<br />OFFICIAL POSITION OF ANY GOVER—d.MENTAL AGENCY
<br />REVEDIAL ACTION
<br />Indicate which action have been used to cleanup or remediate the leak.
<br />Descriptions of options follow:
<br />Cap SM - install horizontal impermeable la-yer to reduce rainfall
<br />C -ontednment Barrier
<br />. B ier install vertical. dike to block horizontal movement of
<br />contaminant.
<br />Excavate and Elispose remove contaiiiinated soil- and dispose in approved
<br />site.
<br />Excavate and Treat - remove contaminated soil and treat ',includes Spreading
<br />or land farming).
<br />Remove Free Product� remove floating product from water table.
<br />L'uml3_ and Treat Groundwater - generally employed to remove dissolved
<br />Contaminants.
<br />Enhanced Biodegradation -- use, of any available technology to promote
<br />bacterial decomposition of contaminants,
<br />Replace Supply - provide alternative water supply to affected parties
<br />Treatent at Hookup - install water treatment devices at each dwelling or
<br />other place of use.
<br />Vanyam jitxaQ - use pumps or blowers to draw air through soil.
<br />Vert TV! - bore holes in soil to allow volatil-ization of contaminants.
<br />No AUVn Required - incident is minor, requiring no remedial action.
<br />COMMENTS - Use this space to elaborate on any aspects of the incident.
<br />SITAT IME - San the form in the space provided.
<br />DISTRIBUTION
<br />If the form is completed by the tank owner or his agent, retain the last copy
<br />and forward the remaining copies intact to your local tank permitting agency
<br />for di_ triblation.
<br />h MEi,al - Meal TwA Permitting Agency
<br />Regional. Water Quality Controll Board
<br />acal Health Officer and County Board of Supervisors or their designee t-:
<br />receive Proposition 65 'notifications,
<br />4, %wne-r/responsiblc party.
<br />
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