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..--`INSTP.UCTIONs � ,
<br /> EMERGENCY . Leak BeiDp, Confirmed- Leak suspected at site, but has not, ht,en confirmed.
<br /> Indicate whether emergency response personnel and equipment were involved Preliminary Site Assryssment. Workplan SubmLttod woaYl,latylLl '1+oral
<br /> et any time r' If so, a Hazardous Material Incident Report shuuLd be filed raqueasted of/submitted by reaponstble party 4.o alntnrmitia whi^t,lier ground
<br /> with the•State Office of Emergency Services (OES) at 2800 Meadowview Road, water has been, or will be, impacted as a result of the release.
<br /> ;Sacramento, CA 95832. Copies of the DES report form may be obtained at Preliminary Site Assessment Underway - implementation of workplan.
<br /> your local underground storage tank permitting agency. Indicate whether Pollution Characterization - responsible party is in the process of fully
<br /> the OES report has been filed as of the date of this report, defining the extent of contamination in soil and ground water and assessing
<br /> impacts an surface and/or ground water.
<br /> LOCAL'AGENCY ONLY Remediation Flan - remediation plan submitted evaluating long term
<br /> 1To avoid duplicate notification pursuant to health and Safety code Section remediation options. Proposal and implementation schedule for appropriate
<br /> 25180.5,.a government employee should sign and date the form in this block. remediation options also submitted.
<br /> A'signatureihere does not mean that the leak has been determined to pose a Cleanup Underway - implementation of remediatLon pl_wi.
<br /> signifi6ant threat to human health or safety, only that notification Post Cleanup Monitoring in Progress -- periodic grt++and water or other
<br /> prbce ,,yr.es hAve been followed if required. morsil.oring at site, as necessary, to verify and/or evaluate effectiveness
<br /> of remedial activities,
<br /> REPORTED BY: a Case Closed -,regional board and local agency in concurrence that no
<br /> EQter,your, Lame, telephone. number, and address. Indicate which party you further^work is necessary at the site.
<br /> represent and provide company or agency name. -
<br /> f IMPORTANT; ' THE INFORMATION PROVIDED ON 'THIS FORM IS INTENDED FOR GENERAL
<br /> "RESPONSIBLE PARTY" STATISTICAL PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REFRESENTING THE
<br /> Enter name, telephone number,. contact person, and address of the party OFFICIAL POSITION OF ANY GOVERNMENTAI, AGENCY
<br /> responsible for the leak.- The responsible party,would normally be the tank
<br /> owner. RLMEDIAL ACTION .
<br /> Indicate which action have been used to cleanup or remediate the leak.
<br /> SITE LOCATION s Descriptions of options follow:
<br /> Enter information regarding the tank facility. At a minimum, you must
<br /> provide the facility name and full address, Cap Site - install horizontal impermeable layer to reduce rainfall
<br /> infiltration.
<br /> IMPLEMENTING AGEIICIES Containment Barrier - install,vertical dike to block horizontal movement of
<br /> Enter names of the local agency and Fegional Water Quality Control Board contaminant.
<br /> involved. Excavate and Dispose _ remove contaminated soil.and dispose in approved
<br /> site.
<br /> SUBSTANCES INVOLVED ExcavaLe and Treat 7 remove contaminated soil and treat (includes spreading
<br /> Enter the name and quantity Lost of the hazardous'substance involved. Roam or land farming).
<br /> is provided for information on two substances if'appropriate. If more than Remove Free Product - remove floating product from water table.
<br /> two substances leaked, list the two. o€ most concern for cleanup. Pump and Treat Groundwater - generally employed to remove dissolved
<br /> ' contaminants.
<br /> DISCOVERY/ABATEMENT Enhanced Biodegradation - use of any available teclusology to promote
<br /> Provide information regarding the discovery and abatement of the leak. bacterial decomposition of contaminants,
<br /> R-e i-IceSuinly - provide alternative water supply to affected parties.
<br /> ,C(,�IINr:I•.�+(:�II:';F Trr,ol.Lrsr4n.'t crt,ll� 1%,111�- i.nsial.l wnt.ar l.regturnnt. devices of onr,h Tkvr I I iair. or
<br /> Cwlir.aLu z,ourUH(n) „I L04, Chv(ck box(um) ind),01.1nr ❑Alla", of luno. Jl.hc,i plArt. of us.
<br /> Vaeu im 1 YLract - uaa punq,s or 111"lwets to draw alr Llu•r.Ileh int!
<br /> CASE. TYPE Vent Soil - bore holes in soil- t,u allow volataiivauiDrn of cost wimr,Antr.
<br /> Indicate the case type category for chis leak. Check one box only. Case No Action Required . incident is minor, requiring no remedial action.
<br /> type is based on the most sensitive resource affected. For example, if
<br /> both soil and ground water have been affected, case type will. be "Ground COtTIENTS - Use this space to elaborate on any aspects of the incident,
<br /> Water". Indicate "Drinking Water" only if one or more municipal or
<br /> domestic water wells have actually been affected. A "Ground Water SIGNATURE - Sign the form in the space provided.
<br /> designation does not imply that the affected water cannot be, or is not,
<br /> used .for drinking water, but only that water wells have not yet been DISTRIBUTION
<br /> affected, It is understood that case type may change upon further If the form is completed by the tank owner or his agent, retain the lest. copy
<br /> investigation. and forward the remaining copies intact to your local tank permitting agency
<br /> for distribution. ;
<br /> CURRENT STAT()S 1. Original -'Local Tank Permitting Agency
<br /> Indicate the category which best describes the current status of the case. 2. State Water Resources Control,'BrIard, Division of Cl.rau Flol;er
<br /> Check one box only. The response should be relative to the case type, For Und^--"ground Storage Tank Program, P;O• Box. 944212, ._ar-rEunanLo. CA -6264-
<br /> example, if case type is "Ground Water", then "Current Status" should refer 2120
<br /> to the status of the ground water investigation or cleanup, as opposed to 3. Regional Water Quality Control Beard
<br /> that of soil. Descriptions of options follow; 4. Local HeaLth Officer and County Board of Super i-;r, r I'll-'Ir ,1!-i�;!I.-^ t-
<br /> receive Proposition.65 notifications.
<br /> No Action Taken - No action has been taken by responsible party beyond 5. Owner/responsible party,
<br /> initial r,lport of leak.
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