|
INSTFXIC n ION
<br />'
<br />EMERGENCY
<br />:Leak_Eeiuz Confirmed - Leak suspectedat site, but has not, been cos;firned.
<br />Foci cate, ,whether emergency respon e y a_scon el -end equfp=ent, were involved
<br />Yr li roar . its -Assn=_ss e t Workplan Submitted - workplan/proposal
<br />at any time, Ifso, a:Hazardous Material Incident Report should lie filed
<br />requested ofls'xbm tted by r,sp.n ibl. party to determine, whether ground
<br />with the State Office of: FmcZgency Se, Jzceszit '(OP.S) a 2800 Nleaduws ew Road,
<br />water has; been, of will be, impacted as a result of the release.
<br />Sacraments, CA 95832, Oo < ep .
<br />}:-Z t form £f[23'�. beClbk:x31.T.G't'�,
<br />P.a of :;?G-' �.,.� ,�._�CJ
<br />>,
<br />FrC'iS;L;."LISoi' :altC iS32y7lPP.3C'T7ta"%Z€ii: O,fi...workplan,
<br />your local underground ^storage t<3R;; permitting agency, rind €Fate w? e her
<br />Pollution Characterization -- responsible darty I's in the process of fully
<br />the OEES report has been riled as of the date of „hzs}
<br /><e ..ort ,
<br />h extent of -contamination
<br />t.%{'ik �.Yii.ii": the ;nn sonm .l, aground water and assessing
<br />npacts on surface and/o« ground water.
<br />LOCAE, er3EvCz ONLY
<br />Rome iaticei Planremediation plan submitted evaluats _g long term
<br />To avoid duplicate notification pursuant to Heai_th and Safety Cade Section
<br />remediation options. Proposal and implementation schedule for appropriate
<br />2518 0'5' ,a &overnment enni yee should agra a.nd date the form in this bloc
<br />remediation o;tions :also submitted,
<br />A signature hers cities not mean that the leak has bee.a detertioned to pose aCleanz'
<br />L*nderwav et<sesta ton cf anemediaticas plan,
<br />significant »0 3iu,s.,n health or safCty, only that otificatiou
<br />Post Cle2ppp Mord,,Lor ins .. periodic ground rater or other
<br />}> wui < Lava been fp, :road if req, ired,
<br />mons cr,.rn>; at site, as n ce_,sa. i> to verify and/or evK. .Lata, e�teet11 neSS
<br />of remedial activities,
<br />REPORTED B, i'
<br />Case C Gtr.�'d `- regional olq. "C'� and .io,^, 3.�. r.�, eZ2i:4<,.% :is: concurrence that i1,'3.
<br />Mratez yocs ramp, t lephor.ne nu.mbez, arid, address< Rndinar'e which party you-
<br />ore
<br />further ccrx is necessaryat the s Ee,
<br />represent
<br />rep e ,ent: and provide company orage yry nen. x.
<br />IMPORTANT il{F IFO FORMATION PROnrTDEE ON TIAs PCS -TS INTENDED Tt3R fSFNI 41
<br />PE.S?'LlNSIBLE PARTY
<br />STATISTICAL PURPOSES ONLY AND IS NOT TO BE CONST3UD AS REPRESENTING THE
<br />Enter game, to apbone number, contact person, -find address of the na_•ty
<br />OFFICIAL POSITION OF ANY GOVERUNtEdTAL AGENCY
<br />Weep r,, b..• for the Leak, The responsible party would noralo'lly he the took
<br />carer.
<br />REMEDIAL ACTION
<br />Indicate which ac o;2rbave been used to cleanup or remediate the task,
<br />SITE LOCATION
<br />Descriptions of options follow:
<br />Ent r information regarding the tank farility, At a minimuni, you mus'
<br />proved that eci-IftY'fWbi d full i4driess.
<br />gap S.nte -- install horizontal imper-moah..e layer to reduce zainfAl,
<br />infiltration,
<br />IMPLEMENTING> GENCIES
<br />Containment rarrle ',Data!! vertical date to block horizontal.mcvcment af'
<br />^near names of the local agency and Ra,g_onas_ Water Quality Central Baird
<br />contaminant,
<br />involved
<br />Excavate and Iispost - remove contaminated soil and dispose: in approved
<br />site. -
<br />SUBSTANCES ES INVO VEE
<br />Excavate and Treat remov'c contaminated soil. and treat (_Ji)c_'1Udes spreading
<br />Ent set tLe ,>«,"*3E' c'n caans,it;y .43.t):st of the h-aza 4ous <.i.. t,nce .in'vo1�7ed, Room
<br />� or land fartna lige,..
<br />is: provided fur ,info-,mation on two ,subotarllce> if appropriate, If fa%ore than
<br />Remove Free Product "" ;""G'.?S!%` e floating product from d7c?te-- ta.bleC
<br />4".`i{i Siza35t.z'iti $:w"° I. sk ,. l..l "vt t;IaG "1'.&7Ck £? Tni35t ^CE1Ceiz3 ?€;.a;'3a.?p, ..._
<br />Piitii3 ._. &" ,.e.t'£a* E'»`ou r Ear "" Acne,,.";..l mglo :,d, i .;.c a�va .,:._, sJ1vcd
<br />tRT+ LL yy�� t
<br />«+IS l:x.'lk',£ 3T.£ ,N1 ....
<br />., _._-�--«...«.».... .........
<br />h :^� i C£^ qq -
<br />x�."'idn - 5,: b «t31,'t+. Et x..,im. A.. c�> available c.a.F.}_Y3 "
<br />..».....�...,._,_.,_&L >S'; F2 '' �' >t. Sih10-- g.," to Y.s%_t3i%PG`te
<br />Pro tide JAa omnat on regardinY the discovery , a.! akalerent, of the I_ ak.
<br />bacterial de om os.iti n of
<br />n_
<br />p.„-.:x.;.:4e alter nat7.v'v' water s'<lI':ply ;o affected pa_r sled ,
<br />:•.w;tUew
<br />'
<br />SO J i,F:r CAS. SD _._.
<br />,.Chet{,
<br />ire a?" nen t at ticik'`;C .?asL,M.._%,1`ea;.','te..cU 4.6'4_ s?u at t:ao:a dwell .."'Ig Cr
<br />Indicate 1urce(.sll of :i,ask, box(e.: :.:;..d1Cc-:ing cause of leak,
<br />ot:'e n1ace or use,
<br />Vacui_ t 't' "? Ul ip €3 k1 LWE. C'U' through R
<br />....,e
<br />£'+ "';oil .� .x 3 a � 7 :7d 7 c€)n 1, a) ?, at , ' ,...
<br />u ;:ne type category ="Cr i.h.�,, a':'.1� Check one �i+:i, only, Cd,:,e
<br />�'d r t, k,.c C;R2 L *„ < . ,. �, Cep :1.., _ 3 e.�...;I ci,1� e i....�;.T «..3,� ,..ts ,C v�,.,Ea 4trs3".�..L.s.fs'.�'>�
<br />type is ;rased ov.a the alost, iie'^sitJ,vo resource c.ffo .<ed, :Kor £�r.:ample, if
<br />kc'tz. ld a_zd 'aoarzt ter have he vn l na
<br />€ a en affected, case 1p-
<br />COn-I RTS Lease this Dac abo�_ on any aspects
<br />�r, s of she incident.
<br />Water" . Indicat:.c, "Drinking Water" ,only ill one or elo,1r , m,a.A:icipal or
<br />dCDmes d water wells have actually been affected, A "tier Ot,nd Qatar'"
<br />SGI.. ?T1:RE Sign the,.., os.m i he space U7"Cs- id rd. :
<br />de _snation, dogs no imply that Lhe affected w_a? -, cannot heor is not
<br />used 'Err drinking aatsr. ,)<w only that water .wells have iof yetAeviI
<br />DISTRIBUTION,aI# T:€:. .
<br />affected' . ✓It is understood chat € a ie type may change upon further
<br />w
<br />I7 t e tG, i.. i oai",.Le ed by the ,ik U :. 2 5 c. .,t, t3.iY'k li. 65 #.'
<br />in a5tJan", i on,
<br />a r a o -g,r wy_ r;; aopies int..._i, to your local iaa?n A agerkcy
<br />:.
<br />for d ist,.ribut.,1,cl n. ..
<br />iiE to �l rS
<br />"
<br />I. Original . '_ aw«-az.-T"sf.as EoMSs_"tsng Age,.ti',"v
<br />znM....3..x.. LS'£�_<. C£€:.�E,, vV wh_.,,.2 bo; 39 ...<.esc_i`1ces the fJYZ.rS°:^vliL Brutus of the iyase�
<br />� �_ iu`t...�.. Sh'-u3as�2 Ii,,...iJ':,$�_.€ y �r�:?asw�i.�lw.,ai: u�_�.,�.,>,:3� offs a4-�.�',r.'S SMf;g,�`caa,",a
<br />Check one S l � o f For
<br />Y i`',n":. 1" aak' ,F f..,,sT,'iPx..>t,. .>1;...'..< d✓.. relative a. o w ... the case ..y'[ie'.. ^ v
<br />� and ., ,. � 1, i C � 94
<br />...I% z .ls. ..;' -;s L, .,AC.,.....e2....k t`.f3 <
<br />2m{ ,. i:.le, .t ca '� 'ty. e. .t_. .,_ou ..,. " �' Curf'ert, sl �u iF€t,. .>hcc _ i l,efer
<br />x`20
<br />to i s,a Ni t;.- .,..3., of h , gLround ,fBL....,.� i.xl'-Tf �
<br />�,_>Uti„,ae or cle ar. A,r, a. or,ec _� to
<br />d: Peg_osa cz a y vcn Y_r .ac., d
<br />-
<br />- 't 1..- Lni ,C i133i`",, O2'iS iR� 3'p�l. k' -s'.> z, ., ,u�:�e-�`;
<br />�§, �� .i! _
<br />".: `airs_ Health .a ?t.«...,.., , , anc-, ..F_63.c. .) )Yz.0 €' b ., i„ al .., ., .....s _,i C _”
<br />receive P ..
<br />No rPior' r, - N€: action ?i-.....; b en taken by respon..x.b L.s; party be -pond
<br />" u
<br />.1 L',S"�i.;e /..,-.s Ponsis-.', _
<br />
|