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I NSTRUICT ION S EMERGENCY ) Leak Being Confirmed - Leak suspected at site, but has not been con=irmed. .Indicate whether emergency response personnel and equipment were involved Preliminary Site Assessment Workplar, Submitted - workplan/proposal at any time. _f so, a Hazardous Material Incident Report should be filed requested of/sunryitted by responsible party to determine whether ground 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. Sacramento, CA 95832, Conies of the GES report form may be obtained at hPreliminary Site Assessment Underway - implementation of workplan_ your local underground storage tank permitting agency. Indicate wether Pollution Characterization - responsible party is in the rocess of fully the OES report has been filed as of the date of this report. defining the extent ofcontamination in soil and ground water aFd assess -g impacts on surface maid/or ground water. LOCAL AGENCY ONLY Remediation =Ian - remediation plan submitted evaluating long term: To avoid duplicate notification pursuant to Bealth and Safety code Section remediation options. Proposal and implementation schedule for appropriate 25180.5; a government employee should sign and date the fart in this block. iemediaticr options also submitted. A signature here does not mean that the leak has been determined tc pose a Cleanup Underway - implementation of remediation plan. significant threat to human health or safety, only that notification Post Cleanup Monitoring in progress - per ther or o procedures have been followed if required. c ground Ovate:-monitoring at site, as necessary, to verify and/or evaluate effectiveness of remedial activities. Enter erTyo By t Case Closed - regional board and local agency in concurrence that no your name, elephone number, and address. Indicate which party you further work is necessary at the site. present and provide company or agency name, IMPORTANT: THE INFO-kMATION PROVIDED ON THIS FORM IS INTENDED FOR GENERALkESPONSIBLE PARTY STATISTICAL PK:'RPOSES ONILY AND IS NOT TO BE CONSTRUED AS REPRESENTING THE Enter name, telephone number, contact person, and address of the ,arty OFFICIAL POSITION OF ANY GOVERNMENTAL AGENCY responsible for the leak. The responsible party would normally be the tank owner. REMEDIAL ACTION Indicate which action have been used to cleanup or re:mediata the leak. SITE LOCATION Descriptions of options follow: Enter information regarding the tank facility. At a minimum, you :rust provide the facility name and full address. Cap Site - install horizontal impermeable layer to reduce rainfall infiltration. IMPLEMENTING AGENCIES Containment Barrier - install vertical dike to block horizontal movement of Enter names of the local agency and Regional nate_ Quality Control Board contaminant. involved. Excavate and Dispose - remove contaminated soil and dispose in approved site, SUBSTANCES INVOLVED Excavate and Treat - remove contaminated soil and treat (includes spreading Enter the name and quantity 'lost of the hazardous substance ivrvolved. Room or land farming). is provided for information an two substances if appropriate. Imore than Remove Free Product - remove floating product from water table. two substances leaked, list the two of most concern for cleanup.' Pump and Treat Groundwater - generally employed to remove dissolved contaminants. DISCOVERY/ABATEMENT Enhanced Biodegradation - use of any available technology to Provide f dy promote information regarding the discovery and abatement of the _eek, bacteria;- decomposition of contaminants. SOURCE/CAUSE R•enlace Su� pply - provide alternative water s.xpply to affected parties _ .ea meta, a lockup - install water treatment devices at each dwelling or dicate sources) of leek. Check box(es) indicating cause of leak. of e. place of use. E TYPE VaclluM Extract - use pumps or blowers to draw air through soil. Ven Sc.i- - more holes in soil to allow volatil' zat con of contaminants. Indicate the case type category for this leak, Check one box only. Case u Y• No P.ction Reo.li.red - incident is minor, req,uirirg no remedial action. type is based en the most s=:sitive'resource affec';.ed. For example if - both soil and ground water have, been affected, case type will be "Ground CO=-iE'TS - Use this space to elaborate on any aspects of the incident. Water". Indicate "Drinking Water" only if one or more municipal or domestic water wells have actually been affected. A "Ground Water" SIGNATURE - Sign tl.e form in the space provided. designation does net .im1:1_y that the affectedwater. cannot be, or not, used for drinking water, but only that water wells have not yet been DISixIeUTI�,I affected. it is understood that case type may „;-range upon further If the form ib mpletpd by the tank owner or : agent I i--- le.ain tine as, copy investigation. and fcrw.ird t' ;gaining copies intact to your tan-'< :;ermitting agency for distribu-.',.n CURRENT, STATUS 1 ig al Tants Fermitt:n� Agency Indicate the category which best describes the current status of the rase. 2. S t 3' cis tr Boa Check one box only. The response should be r=lative to the Cass t For t T k Program.e_{.Imple. if case tyn�2 _Js "Ground Water". '^en "Curren`. Status" sr refer � Storage g at- �... _ e:..., t_ to '.he status o° e round water Un P.O.a.r i luves:.m—on or cl=_an+.:p. as op to 3 a L ( : n �r cu 1 titer a e yr Ra Qua'it • Control roard Chat of sol.'. _,. _eons of options follow: 4. Lc fiver and County Bound G5 ot:i` cats ns. No Action T n - `3o action has bear: taken by responsible parry .=t-:t ? t;l arty, initial. _ ;p.,, of _ar::k, `