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INSTRUCTIONS
<br /> EMERGENCY leak Bein Confirmed - Leak suspected at site, but has not been confirmed.
<br /> ods cafe'whether emergency response personnel and eggipment were involved workplan/proposal
<br /> at any time. If so; a Hazardous Material Incident Report should be filer requested of/submitted by responsible party to determine whether ground
<br /> with the State Off:ice? of Emergency Services (OES) at 2800 hleadowsriera Road, water has been, or will be, impacted as a result of the release.,,„
<br /> Sacraments, CA 95a32. Copies of the O S report ford may be oba ained at I'reliminaxv Site A scssment Underway - implementation of workplan.
<br /> your local urdergroxrnd storage took I=>erulitting agency. Tndicate whether Po lug>_on, C'haracte_y.zauic r�s> ns die,party is in 2�e process cf full
<br /> the O'ES report ha_, been filed as of the data o� this report, defining the extent of contamination n soil. and ground water and assessing
<br /> s impacts oda surface and/or ground water,
<br /> .
<br /> LOCAL AGENCY ONLY ��, �i�iion Plata -- remediatilon plan suhn.tted evaluating long term
<br /> sC - ;,u1d � �°ac_re
<br />' `1o. avoid duplicate notification perauact to Health and Safety code Section rere:diation options, Proposal and mpl_mer a;:>ion schedule for appropriate
<br /> 25120.5, agoV°ernment employee should szgn and dat>e the form in thss bioek. remediation optaot:s also'submitted,
<br /> A signature here doss nit meat that t.e leak has been det.ennined'fo,pose a Cleaaau' 'u?derw<i implementation of remediation plan,
<br /> significant threat, to T3uS an health or safety, orally that notification _'oat." le..,,u-pi tao..ito-inn. ins Pry - periodic ground water o other
<br /> procedures have ':,een fo :owod if 7euuirel- monitoring at site, as .ne essasy, to verify and/or eva.caate effectiveness
<br /> of remedial activities,
<br /> REPORTED BY Case Close=d -,regional beard and local agency in cortcurreaace that no
<br /> Ener y.Zr came,; telephone number, and address, Indicate which party yea Kia her work is necessary at the site:
<br /> represent and provide company or agency name.
<br /> 'MP OR ddT: THE T'1BOaAK TION PROVIDED ON THIS FORM IS INTENDED POTS GENERALRESjPONS"CiLB', ?ARTY STATISTICAL PURFUSES ONLY AND IS NOT TO BE CONSTRUES AS REPRESENTING THE
<br /> Enter name, telephone number, contact person, arid address of the party OFFICIAL POSITION OF ANY GOVERNMENTAL AGENCY
<br /> responsible for the leak. The respoas3b'e party would normally be the tank
<br /> ow ern RE!-EDIAL ACTION
<br /> indicates wh ci action have been used to cleanup or remediate the Irak.
<br /> SITE LOCATION Descriptions of options follow:
<br /> rkte�r i,4 ors atio ., Axdl rPy tbe-tank n city, At a minimum 'yaax dust
<br /> provide tbxfaoa sty e.,�. tall slres,.,< -A isnot i install horizontal impermeable laver to reduce rainfall
<br /> infiltration,
<br /> IMPLEMENTING AG NCIES Gortai merat Farrier - install vertical dike to block'hbr zostal movement of
<br /> Enter names of-the local agency and Regional WaterQuality Control. Board contaminant.
<br /> involved, Excavate anti C) sp remove contaminated soil end dispose in approved
<br /> sato,
<br /> SUBSTANCES INVOLVE) Excavate and Treat - remove contaminated soil and treat 0n _;udes spreadMg
<br /> Entex the name and quantity lost of the h. zarcoua substance, involved, Room or land -fanning),
<br /> is prrvided for:information on too subsaucet if appropriate, If more, than Re>r,o Free Product - remove floating product from watux table.
<br /> two subst roe"s lerakod,, dist the two of €rest. concern for cleanup, x, r art rea,3 Groundwater - geneca?ly employed to remove dissolved
<br /> --
<br /> contaminants,
<br /> ETSS`vVl'hY_4sAT.ME0T Enl'a...ca; a3.uoe .a.ad .a ira - use of any az?iT.aL,e ted#ara[7c..gy to promote
<br /> Provide it o_mat...r_ regarding the disco eiy ar;d abatement of the leak, bacterial decomposition of contau ax t
<br /> provy.de alternative water supply to affected parties.
<br /> SOIJaC;EAU§,K r reatf as "t> doak 13 -- instalI aka er a,,-ea,.cas,nt devices a. r., M.„na dwelling or
<br /> Indicate sou te(a;) caf leak. Chock nor es, .....didatwng cause of leak, other r , . c of use,
<br /> Va, x m l u pump or b cse e draw s a r tl,rs of sGiLl
<br /> .: en
<br /> CASH ..> Vent Soil _; hole's in soil 3r a]Ic"s o a:i' of
<br /> Izud2cate the c>ar�, type` catenary for ,ch Ie'a . Cbe'ck one sox only. Case flo A first, lieaqLl Ld - ineidentz, .aa minor, requiring .ci rem dlal action,
<br /> type is bared ts:, the most sesnritive resoance afte_aedi For example if
<br /> both son_' dd,,g guild water i:aue been af” ctea, case type will be `Ground E,0.-I�ZNTQ° Use this space to elabara en. an aspects of the incident.
<br /> t.
<br /> a
<br /> Water" 114iprinking"Water" only if lane or more'municipal or
<br /> domestic natter rapl_I_s knave actually been affected. A, "Ground Water" �IGNLAnRl. - Sign trhp,fcasrm in the space provided,
<br /> desig2natio; does not imply that the 'affected water cannot be, or i.., not,
<br /> ` out, only than � ," � yet been 135 Pkat rill
<br /> used tear a irkirt„ wa�wr, ,� wells have not
<br /> affected, It is understood ''.list case ty
<br /> e may change upon further if the form is completed by the tank owner ar his .gent, retain 'Ale !as'. copy
<br /> investigation and forward the remaining >;ar;;es intact to out 1t3ua�.ra,,rk :amiu> Wit, Try
<br /> w
<br /> CURRENT ;.STATUS 1. Cs igiral], - Local l Tank Permitting Agency
<br /> In _c.a e Lee rata tory which best -no c.,,rreut �t,at us sat t h ca_ . State. Resources _ a
<br /> st des. a xFl> s s 2. to our .W_. I is t u luno, r yrs
<br /> Check opo cy, aaa;y, The tea Inonse shoalw.b�e r,,.l llivo.to the case type. per
<br /> nd rgi.ound Sto-rage Tang ._ogra, F,0, Box 9449-12, a w..a,.r. t.._ 94241-
<br /> ct ...3s e _f case type it Ground tlater", tk,an c„..rexrt Ctatc..� ?_ u.:er 2,�C
<br /> .... ex „.,.,a r t; ?e }'r tt, 'tu .f C,c tro' and
<br /> to the ,t s o a grc�zxac3 ,.� 've as;:ataozr o. cSea..up, as opp� o
<br /> sea ab a a
<br /> th._,t, of coil, Descriptions of options follow: {_ Local caeal ,j an at,".y�Board, of SUp'e1..r_. , s c._ es>`,'ne-" to:
<br /> rece-i-ver ro __10n 65
<br /> No Action .:al *; " ,lir action. etas been taken by responsible party beyond ,.
<br /> i't:_r a,a' Iac,IK.
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