UAR/PROP 65_PRE 2019 - Laserfiche WebLink

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INSTRUCTIONS EMERGENCY Leak Being Confirmed - Leak suspected at site, but has not been confirmed. Px 1' i ry Sit A ssme t Workplan Submitttte - workplan/proposal. - Indicate whether emergency response personnel and equipment were involved requested of/submitted by responsible party to determine whether ground at.any time. it so, a Hazardous Material Incident Report should be filed. water has been, or will be, impacted as a result of the release with the Btate Office of Emergency Services (01151 at 2890 Meadowview Road,. water inary Site As sassment Underway - implementation of workplan. Sacramento, CA 95632. Conies of the GES report form may be obtained at pollution Characterization - responsible party 3s in the process of fully your local undergound storage tank permitting agency. Indicate whether defining the extent of contamination in soil and ground orator and zssess irg the OES report has beenfiled as of the date of this repastimpacts on surface ,and/or ground water. Remediation Plan - remediation plan submitted evaluating long term LOCAL AGENCY ONLY remediation options. Proposal and implementation schedule for appropriate To avoid duplicate notification pursuant to Health and Safety code Section remediation options also submitted. 25160.5, a goverC*nt employee should sign and date the form in this block,health or safety. only that. Cleanup Underway - implement of remediation plan. A signature here does not mean.that the leak has been determined to'pose a Post C1 tp Monit 'ng in Progress - periodic ground water significant threat to hwaor other en t notification monitoring at site, as to verify and/or evaluate effectiveness necessary, procedures have been followed if required.- - of remedial activities. _ Case Closed - regional board and local agency in concurrence that no REPORTED BY further work is nee-e�sary at the site. Entex your name, telephone number, and addiess. Indicate which party you UJ epresant and provida company or agency name. '" IMPORTANT: THE INFORMATION PROVIDED ON THIS FORM IS INTENDED FOR GENERAL RESPONSIBLE PARTY STATISTICAL PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REPRESENTING-THE p p and addiess of t{te party - OFFICIAL POSITION OF ANY GOVERNMENTAL AGENCY Enter name, tale hone number, contact erson, - ormally be the tank responsible for the leak. The responsible party would REMEDIAL ACTION owner. Indicate which action have been used to cleanup or remediate the leak. Descriptions of options follow: - SITE LOCATION Enter information regarding the tank facility. Rt a minimum,.,you must Cal) Site - install horizontal impermeable layer to reduce rainfall provide the facility name and full address. infiltration. Containment Barrier - install vertical dike to block horizontal movement of IMPLEMENTING AGENCIES contaminant. Enter names of the 1anal agency and Regional Wate_ Quality Control Board E to and Dispose - remove contaminated soil and dispose in approvod involved. - site. Excavate and Treat - remove contaminated soil and treat (includes spreading SUBSTANCES INVOLVED or land £arming). - Enter the name ma quantity Post of the hazardous substance involved. Room Remove Free Product - remove floating product from water table. is provided for information on two substances if appropriate. If more than two substances leaked, list the two of most concern for cleanup. Pump d Treat Groundwator - generally employed to xemov dissolve contaminants. Enhanced hanced Biodegradation - use of any available technology to prpmote DISCOVERYJABATEAENT bacterial decomposition or contaminants. Provide information regarding the discovery and abatement othe leak. Replace Supply - provide alternative water supply to affected partes. - T tme SOURCE/CAUSE at Hookup - install water treatment devices at each dwellir.3 other place of use Indicate sources) of. leak. Check boxes) Indic sting tease of leak. Vacuum Extract - use pumps or blowers to draw air through soil _ Vent Soil bare holes in soil to allow volatilization of contaminants 'SE TYPE N Action Required - incident is minor, requiring no zemodial action. Indicate the case type category for this leak. Check one box.Only. Case type is based on -the most sensitive resource affected. For example, if COhMENTS - Use this space to elaborate on any aspects of the incident. . both soil and ground water have been affected, case type will be "Ground IR Water". Indicate "Dri;rd:ing Water" only if one or more municipal or SIGNATURE - Sign the form in the space provided. domestic water wells have actually been affected. A "Ground Water" designation does not, imply that the affected water cannot be, or is not, DISTRIBUTION used for drinking water,..but only that water wells have not yet been If the form is completed by the tank owner or his agent, retain the last -. affected. It is understood that case type may change upon further and forward the remaining copies intact; to your local tank permitt_ng age — investigation. - - for distribution. - + CURRENT S"'ATUS - 2. I. Original - Local Tank Permitting Agency W - State Water Resources Control Board, Division of Clean 'Water Programs.. Indicat.e the cattagory which best desdr ibes tt, orient status of the case. Underground Storage Tank Program. P.O. Box 944212., Sacramento 6A 942s. Chack one box-only. The response should be lativa to rho case type For2120 example, if casekLype is 'Groupd Water o"".en Current. State shoild 'efer ,� :s. Regional Water Quality Control Board to the status of the ground water iuvestigat m or �Iean;P. P: do4, Local Health Officer and County Board of Supervi.=ars rt their designae Chat of soi L, Descriptions otmoptions fol'-o'w: receive propos icimi tis notifications. pa. Own=_r;ie,pon ible party. N . '<'dor f k_ - No a tion i:, be,,u tak e nv -ear one;.tic rtv 'u-1 r-Y.