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p.NSTRk"CT ION
<br />EMERGENCY
<br />L ae F3ei;1 Cozxf..5x;zcd Leak suspected at site, but has not been confirmed,
<br />indicate whether emergency response perso..nel and equipment were involved
<br />Fre im .nary Site rsse smen Woxknian Sub .itw i -' vokp:,..<;./prcpcs
<br />at any time. If.so, a Hazardous'Ma.,er_,:al. ,c s.:ent Report should be filed
<br />requested of/submittedw by responsible party to determine eche- ground
<br />wit3? the Stato'Office of Emergency Services (OES) at. 2800 Meadowview Food,
<br />water has been, or will be,, impacted as a result of he lease
<br />Sacramento, ,'A 95532 copies of the CES report form may be obtained as
<br />I x e iit;inar Site r :as menu w , derway - Implementation of we-p?on,
<br />your local underground sac -rage tank perrnitt ung agency, Indicate whether
<br />1.lution C'haracte iza c�: r, xis b?e party ws zn ::e -,roc s. L iu iv
<br />the OES revort has be§:: n, filed a..� of the date of this repart,
<br />defining elle extent jos coil taatinat i o.., 5oil. a?a'.: ,,,_E33,xS.:; water and assessing
<br />Mpacts on surface and/or ground wa.a--
<br />LOCAL AGENCY ON i,Y
<br />plan �i PiJi. vL� Er.? LF �¢'� iJ �., r�9.ikT
<br />To avoid du_r,Lacate notification pursuant to Heath and Safety cu , Section
<br />remediation notions:Proposal- and Impleatentetion -_,cl odu'.w for appropriate
<br />251dd. , a government amp cyte should sign and date the I nm ih this bloc:
<br />remediation options also submitted,
<br />A signature here' does not Crean.. that the lea..k .has been 'determined to pass` a
<br />CYtleans, ? U,"dd rways - implener?.tati.on of reE'aedAcation :'�i�.an,
<br />,significant threat. to iT1<man health or m afety, on'. that notification
<br />tiTJ xn Cz.ecltiLi 3:��C3:Si torn 252 :.Fz� a�.:..5 periodic g:ru.:.td fiX<z .,w_ >)r other
<br />procedures YSaV.,- been followed l.:t .ra,gt.a_m�s;a.
<br />mo.?ii.t7;:IT;(',,, at site, as re,_ossary, to J"v':`ify oval:ate effectiveness
<br />of remedial, activities,
<br />RERt3RTEFl BY
<br />Cate Closed -; regionel board -and ic,cal agency in concurrence that no
<br />Ester your name, telephone; narber, and addres. s. s indicate wcirb party yo, x
<br />Farther work is nede'6sary at the Site,
<br />and provide company or agency name.
<br />ORESPOLSIBLF
<br />IMPOx ANT=THE !NF0TU11 TION PROVIDED ON TIRIS I` IMI IS INTENDED FOR GMERIi3,
<br />PARTY
<br />STATISTICAL , ."RPOSES ONLY AND iS NOT TO BE CONSTRUED AS FEFRES1N TIM E
<br />Enter name, telephone numbor, contact person, and address of the party
<br />OFFICIAL POSITION OF ANY vs°)TEUTTMILNTAI AGENCY
<br />responsible for the leap. The responsible party would normally be the tank
<br />c e'r
<br />1i.LMEDIj,L ACTION '
<br />Indicate which action have been used to cleanup or retnadiate ache leak,
<br />SITE LOCATION
<br />Descriptions sof options follow:
<br />Enter information regarding. the tarok faC4lity. 'Ar, a minis un, you meat,
<br />provide the facility name and full address'
<br />Cap Site - instaU horizontal impermeable layer to reduce rainfall
<br />infiltration,
<br />ItRi'L 'T3NG AG ;NCT
<br />i nntazrr;e,tBarrier .sirl�vertical ll_ to block t .,rx74ita1 movement 01
<br />:
<br />Enter names of the local area.y xt Eag-„, X,Quality Ceri.vl marc
<br />csx t,am-itart.
<br />involved.
<br />Excavate and 2,2,p_ose remove, cc<taa.._nate l soil. and dispose -1 n approved
<br />Site,
<br />SUES xANCES 7yJCLT
<br />c� at : -n_ Teat- remove cantatinated soiland treat "tnc l dnspreading,
<br />" Enter the name.. and I',aantityo. st of the haLardous, substance ,in o-1 ed', Root
<br />or land farming).
<br />is provided for information on two substanc_a if appropriate. ii s.io_-e than
<br />Remove Free Product;;: " remove fLci<atJnj'.,, jrC'duc; froln water ..bl1 '.
<br />two aLt}.'35t8riCL-`S leaked, lift ti?e t;�tQ 'J.i' ;S1Cpt c�:r:acorn �L3r. G1.23T2Uni.
<br /><#.,., ?n,., Treat_ ,-fy{li"sOw ter -' �'eP, u'r3:...y emploU,yee to ,.. ,,,aCe disa=.vea
<br />_m i -.:.�
<br />m
<br />cot,yam nant,s.
<br />i1I5^Oa'Ei2YIA AT,i;...i#i
<br />ll C:dd .code rad.L- use of any available teciinoiogy "e'„3...pi,—omi e
<br />SPZo'41de inforr at. .caz. .:.G'a.,'ariii ,i t, a1sco ery and; abatement of the _._c<.k
<br />bacterial d eco':piCsit].£i:._ of co., am,.;nants,
<br />p-rovide alternative water supply to of -ec,ed p',ar les ,
<br />C'iAinsta;.l water t-rec.:mcn-1, devf ces a' each dr'eiling o.r.
<br />indicate Z'ouresls)s of Isak, Check box(ea) indicating cause of leap..
<br />J er placeof use,
<br />vacutae ExCtut use pump Gi ["s'wa t o draw r th gl3 Jif
<br />ASE TYPE
<br />pct . room _. holein. sol r,. allow, -vo ati, , Za mon of costa„ ,aa_:,.,>.
<br />Indicate the Laze type category `�t?r L"11.5 l:J.zi, %,:,ecli. Gne l>G`i." c:�1:y. <, ...::<3
<br />ap} �' i 1 `S .; C�uired - inr ::Lent :nor, r•L'.gt<. ,1., .te.medial action,
<br />type is based Gil the most sensitive rE'rtCflrL,e c.t F'e C:.E'd, For example
<br />both so_i and ground wal.er have been at dct 1, case type will be -Ground
<br />Cr rN .; m Use 9,htsj_,ar.e to elabo:,ar,e .on any aspects of the lnc„c;ent,
<br />Water". indicate " D .=.;F ir.,, Water' only if 0.10 or more municipal or
<br />domestic water wells have actually been affected, A "Ground haler”
<br />SIGNATURE Sigu the form in the space provided,
<br />designation da,., r= t _4
<br />U,q)-ly th ,, the affected water cannot he, - i a not,
<br />used for drive i ng ,later, no, n ' y he' wa.,er wells have not yet been, :
<br />f I:iTr ze}I i;t
<br />of"fected' is ,»nd at..;f.d ,.,%t {'asp type E3.3y change upon %L'I'a,'her
<br />If the ion'l{, by the tank c,on.._ C';" hir, a,�i;<.t. ..Gr,.a_.2 ...w last '_ctpy :
<br />aaaJest_ga,, cn.forwa�;
<br />th r a,aizt_.ag copies it;lect f,:) you'_ ..,v; „ellspells ittlrn? agency
<br />to r , 1 F, tori oza.
<br />zaI 1
<br />r
<br />.t,. cat the caY..a'l ox. wh Bch'nest , scrE, trot ^. rren., status o .,.
<br />a
<br />u a
<br />�, :T n.b .. a� � Resources t.�Ce.,u Mnn' ., � u ,
<br />C'Ilie4;k one ,'.;ox only, _h,' _-e Y.,�x1..c „>I.oal.;i {„v, ..:..tat.".e- t,o t1h case # ... ..
<br />l.ld :.g uund Storage Tank 13-o .. . ,.,....... 944212 ... ., � 9L,24 -
<br />t..
<br />example, d
<br />xma_ t» .. _..
<br />the _1a of ?,,,e u}.....�. "._? er Lr C.,� 1. _.,,c Rai up, as .,L7
<br />.t, „Lm. :1 Qualjty Coat ',.l Board
<br />,3,
<br />z 's> c.=a,
<br />ocs , fi rot' and C_=c,, ant . _ i of to
<br />F.� Action. TartTakeu No actiinnq= --lbeem ? by ,-J>'a_�1.� ??._.,T
<br />i). Party
<br />. _
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