SITE INFORMATION AND CORRESPONDENCE

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INSTRUCTIONS CURRENT STATUS EMERGENCY ndicate the category which best describes the current status of the case. ?ridicate whether emergency response personnel and equipment were involved at Check one box only. The response should be relative to the case type. For any time. Sf so, a Hazardous Mefer to aterial incident Report should be filed with example, if case type is "Ground Water then "Current Status" osedldtorthat of be obtained at your the status of the ground water investigation or cleanup, as opp the State Office of Emergency Services (OES) at 28D0 Mcadowview Read, soil. Sacramento, CA 95832. Copies of the DES report form may local underground storage tank permitting agency. Indicate whether the OES IMPORTANT: THE INFORMATION PROVIDED ON THIS FORM IS INTENbED FOR GENERAL report has been filed as of the date of this report. STATISTICAL PURPOSES ONLY AND i5 NOT TO BE CONSTRUE[} AS REPRESENTING THE LOCAL AGENCY ONLYOFFICIAL POSITION OF ANY GOVERNMENTAL AGENCY Ta avoid duplicate notification pursuant to Health and Safety Cade Section ACTION 25180.7, a designated government employee should sign and date the form in In iREMEDIAL DIAL whit actions have been used to cleanup or remediate the leak. this block. A signature here does not mean that the leak has been determined Descriptions of options follow: to pose a significant threat to human health or safety, only that notification procedures have been followed if required. Cap Site - install horizontal impermeable layer to reduce rainfall REPORTED GYinfiltration. Containment Barrier - install vertical dike to block horizontal move:?ient Enter your ate which party you name, telephone number, and address. Indico contaminant. represent and provide company or agency name. Excavate and Dispose - remove contaminated soil and dispose in approve. RESPONSIBLE PARTYsite. Excavate and Treat - remove contaminated soil and treat (includes Enter name, telephone number, contact person, and address of the party spreading or and farming)- responsible for the leak. The responsible party would normally be the tank Remove Free Product - remove floating product from. water owner, tab e. SITE LOCATION Pump and Treat Groundwater - generally employed to remove dissolved rnter 5nfarmation regarding the tank facility and surrounding area. At a contaminants. y romote od minimum, you must provide the facility name and full address. Enhanced Biegradation - use of an available technology to p bacterial decomposition of contaminants. 1 to affected IMPLEMENTING AGENCIES Replace Sully - provide alternative water supe y Enter names o the local agency and Regional Water Ouality Control Board partes. Treatment at Hooku - install water treatment devices at each dwelling or involved. other p ace of use. SUBSTANCES INVOLVEDNo Action Required - incident is minor, requiring no Enter the name and quantity lost of the hazardous substance involved. Room is remedia action. ,tion on two substances if appropriate. if more than two provided for inform bstantes leaked, list the two of most concern For cleanup. COMMENTS - Use this space to elaborate an any aspects of the incident. so IGNATURE - Sign the form in t}le space provided. DISCOVERY M ATEMENTDIS7RI�UTIDN provide information regarding the discovery and abatement of the leak. if the form is completed by the tank owner or his agent, retain the last copy SOURCE/CAUSE and forward the remaining copies in tact to your local tank permitting agency Indicate sources) of leak. Provide details on tank age; capacity and for distribution, material if known. Check hax{est indicating cause of leak. 1, Original - Local Tank Permitting Agency 2. State Water Resources Control board, Division of Water Quality, CASE TYPE Underground Tank Program, P. 0. Box 100, Sacramento, CA 95801 3 Regional )later Quality Control Board Indicate the case type category far this leak. Check one box only. Case type Board of Supervisors nr designee to receive Proposition 65 is based on the most sensitive resource affected. For example, if both soil 4. County and ground water have been affected, case type will be "Ground Water". notifications. Indicate "Drinking Water" only if one or more municipal or domestic water 5. owner�responsihle party. weds have actually been affected. A "Ground Water" designation does rot imply that the affected water cannot be, or is not, used for drinking water . but only that water wells have not yet been affected. It is understood that case type may change upon further investigation.