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<br /> INSTRUCTIONS'
<br /> EMER}6ENCY ;- )'CURRENT STATUS ) '
<br /> n tate whether rgenCy response personnel,and egbment were involved at i' n reale e.category which'best describes the current status of the case.
<br /> Check one' box only. The_,response should be relative to the case type. For
<br /> ariy ime. ;If so, a Hazardous,Material?Incideht Repo-t should be filed with u then "current Status" should refer to° ,
<br /> rhe State Office of Emergency Services�(OES) it 2800'(eadowview Road, example, f case type i's]"Ground Water
<br /> `Sacramento„ CA `95832. :Copies of the DES report farm ma;y be obtained at your -, (' ; the status of'the ground water investigrtion or cleanup, as opposed to that of)
<br /> 3ocaelr` -dea,`ground atorage tank permitting agency. Iieate whether the DES
<br /> soil:
<br /> port as been filed as of the,date of this report. . i THE INFORMATION PROVIDED ON THIS FORM IS INTENDED:FOR GENERAL
<br /> s ! IMPORTANT:`
<br /> LOCM AGENCYONLY ) STATISTICAL PURPOSES ONLY AND IS NOT TO.BE CONSTRUED AS REPRESENTING THE
<br /> i�avo ups cafe natificatian"pursuent to Health end Safety Code Section g ° OFFICIAL POSITION OF ANY GOVERNMENTAL AGENCY
<br /> 180:.71 a designated government employee should sign and date the form in ':'REMEDIAL ACTION °
<br /> thii block. A signaturehere does not'mean that the',leak has been determined a
<br /> to pose a significant threat ta�iuman health or safety, only that notification 'Jn Cate w c�actions have been used to cleanup or remediate the leak. ).
<br /> procedures have been followed if required. z,`
<br /> Descriptions of options follow
<br /> s Ca Site - install horizontal: impermeable layer to reduce.riinfall
<br /> REPORTED BY _ =
<br /> nter.your name, telephone number, andaddress. Indicate which party ypu'' n tration.
<br /> represent and provide company or agency name. Containment Barrier : install vertical dike'to block horizontal movement #
<br /> �. o con ami pant.
<br /> 'RESPONSIBLE PARTY Excavate and Dis ose�- remove contaminated soil and dispose,in approved
<br /> 4 nter:name to ep one number, contact person, and address of the party:
<br /> ;responsible for the„leak iJ;esres ons ole arty would normally be the tank
<br /> and Treat - remove contaminated soil and treat (includes
<br /> P ( f ' spreading or an farming).
<br /> f "owner. _ ;.Remove Free Product `- remove floating product from water
<br /> L
<br /> SITE DATION r
<br /> table.
<br /> e
<br /> Enter ,n ormation'regarding the:tank fi(cility and surrounding area A1�a Pum and Treat Groundwater generally employed to remove dissolved
<br /> inimum,you must;provide,the facility name and full Address. ' eontam Hants. ;
<br /> ; r #; Enhanced Biodegradation - use of any available technology to pronate
<br /> ;IMPLEMENTING AGENCIES i`°
<br /> ° acter,A decomposition of contaminants.
<br /> nter_nameFo e( ocal,agency and Regional Water al#ty Control Board a Replace Supply provide alternative water supply to affected ,
<br /> sinvglved
<br /> parties.
<br /> :a ;, a ,- Treatment at Nooku instalh water treatment devices-at each dwelling or
<br /> SUBSTANCES'INVOLVED § i ' other place o Use.
<br /> ' No,Action Re uYred incident is minor, requiring no
<br /> nter,t"e._game an quantity lost of th$ hazardous substance involved.' Room is
<br /> reme a action,.—
<br /> aided for information on two,substarces if,appropriate. ` If more 'than two
<br /> v`
<br /> -Substances leaked, list the two of most concern for cleanup. t iOMtdENTS = Use this�� space to elaborate on any aspects of the incident.
<br /> ' ( SIGNATURE Sign the form in the'space. provided, it
<br /> ,DISCOVERY'%ABATEMENT ; ION
<br /> r rov e n ormay on regarding the discovery and abatiment of the leak. {
<br /> -If the form is completed by the tank owner or his'agent, retain the last coPY
<br /> 'SOURCE/CAUSE = and forward the remaining copies 'in tact toour local tank permitting agency i
<br /> -. Indicate sources of leak. Provide details on tankage; capacity, and , iAfor distribution.
<br /> i waterial%if known. Check box(es) indicating pause leak. k Opf.9ina1 Local,Tank 'Permitt;ing Agency
<br /> < .
<br /> 'CASE TYPE= ” n Ba rd Division of Water Quality, A
<br /> 2 State`Water Resodreds C9 trol a
<br /> Underground Tank Prggrae, PD. Box'100,'`-,,Sacramento, CA 95801
<br /> n ca 4 thecase�type categoryfor this leak, Chec one box only. Case type 3. Re ional Hater QualtyControl Board
<br /> is based on the most sensitive resource affected.. or example, if:both roll g g "
<br /> and roup water havebeen affected, case type will„ke "°Ground Water'". . k 4. County Board o Supervisors or designee to receive�Proposit#on 65
<br /> -ground : notifications. >
<br /> -indicate "Drinking,water" only if one or more,muni cipAl or domestic water ~ ;s- '' 5. Owner/responsible party
<br /> s reds have actually been affected. A ",6round Water designation does not �, a
<br /> mPly that the affected water cannot be, oris not, sed,yfor drinking water,
<br /> but :only, that water wells have not yet,,been affected It is understood'that
<br /> \. „cls type may change upon further inveitigatipn. ,,, ,
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