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State of California-California Environmental Protection Agency Department of Toxic Substances Control <br /> TIERED PERMITTING PHASE I ENVIRONMENTAL ASSESSMENT CHECKLIST <br /> AREA OF CONCERN DATASHEET <br /> IrLstr€rctiorts:Complete the following questions to detail for EACH release or suspected release identified.in Section.1I1.FACILITY WALK- <br /> T ROUGH IISISPLCI1ON-SPECIFIC ARLAS or SE 7100 IV FACtLUY WALK-THROUGH INSPECTION-OTHER AREAS and any <br /> other known or suspected releases. Do not include areas that have been or are ging,remediated tinder the oversight of an appropriate; <br /> agency. <br /> 11 If answers to questions are not known,then state"unkno-wnn_ <br /> 1. Facility name: <br /> ..................._..._................._................................................_............_...._..................__....__.._.._....___............ ............. ...._____.................._................_..._...._....._.....__...................___.... ._._.._._......_......................._.._.._....._..._....__..._....__......._......... _.._....: <br /> 2. This sheet is being completed for a: <br /> Known release Suspected release <br /> 3. How was this release or suspected release discovered? <br /> During the walk-through inspection? Previously known release? <br /> What checklist question(s)are related to this release(section/question) <br /> 4. When did the release occur? <br /> il 5. What was released and how much? <br /> 6. What caused the release? <br /> 7. Indicate the approximate area of the release(e.g.3 feet in diameter,5 feet X 4 feet.) <br /> 8. Was the release remediated? IES,explain how.(Note: A datasheet need not be completed for <br /> If Y <br /> releases remediated or being remediated under the oversight of an appropriate agency. <br /> j <br /> 9. Were samples collected?If yes,what were the results"? <br /> 10. List any environmental reports or studies performed on the area of concern and attach copies or summaries of <br /> the reports not submitted to the Department. <br /> Name of prepares: <br /> Title of preparer: <br /> Date: <br /> DISC:1151(06199) Please indicate total number of pages_of <br />