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INSTRUCTIONS
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<br /> Et1iRGENCY Leak-Bain Confirmed•- Leak suspected at site, but has not been annfiFmed.:
<br /> Indicate whether emer e cy ? spnn a per qR el and a uipineni were 'i�nvoivec '' Ixolimina Sire Assessment.Workrlan Submitted - warkpla lPraptsal,�,�,-#
<br /> at any time, If $
<br /> a, a Hazerdousliatarial•lnc'i4ont Report should A filed fes. �� requested of/submitted by re`s�onsibla party to determine whether'wound.
<br /> "with the`W ate office Fmergencr Services (PES) at 2.G00 6ieadnwTiew Rdid� t� �^ water,.has been, ar wtll be, impacted a's a'result of the release.
<br /> Sacramento -SCA 95832.. Copies of..-the OESy�'epurt} f0mr..'may he pbtaired at 0A Pre!imina Site Assessment Itnderw< - implementation of waxkplan,' j, Ii
<br /> your .Local'underground storage tank perr"rtting"agency: :ndiv`ata v>h2the_� ''` PoIL&Aon Characterization - responsible party is in the process of_fuily i
<br /> the OES report has beef filed ;as, at the date at this depot r` �, � +� defining the extent of contamination in soil. and ground water ab ziss+s.sang
<br /> ,.., �. impacts on surface and/or. ground water... +9
<br /> LOCAL AGENCY ONLY ! :Remcdaation Plan - remediation p an submitted evaluating longm
<br /> To.avoid duplicate xtot•ification pursuant to Health and &afet4 cnd rSeati n romedaation options Proposal and implementation schedula'forr B etc
<br /> 25180.5, a goveznment employee sl�uld sfg and-date the �ri in this black. xametiation options-also submitted,
<br /> A:signature here does not'mean that the`leak teas be�fC determinodrta po e....�a j , (J+' Cleaz�un Underway - implementation of remediation plan. .� � 0 � f
<br /> signrilcant=threa .hu�nan 7ieal h aF s ety,, only that rintificatinn Wn
<br /> r Post Cloaca Monitari > in
<br /> t'toPro pe s periodic ground water or otherF
<br /> p oced==fixes have beari�olLawed i „Ferruired± <, ( ,/ r +'"'� mottitging at site, .as necessary, to verify and/or evaluate effecte��sa
<br /> of remedial activities.
<br /> RcFORTtD BY w, ,. � •+` ' Case r—used - rani opal board and local agency Try concurrence zh ft ztn
<br /> Enter your name, telephone number-�'and audress` Iadli� ay.e.ffiich paxty-Yaw L- further work is necessary at the site. I
<br /> c represent and provide 06mpany or agency name. !f�
<br /> ✓ IMPOTxTANT-: THE TNF'ORN]ATION .PROVIDED ON :TFIS:FORM IS INTENDED PO4 GENEAAL_.,
<br /> r
<br /> RESPONSIBLEPARTY STATISTICAL PUR SES ONLY ANDIS NWT TO BE CONSTRUED AS PEPRESENTING THE
<br /> Enter name, telephonemumber, contact person, and addressfepf the party CPIICIAL PO! TT {1P7 GF; GOVERNMENTAL AGENCY ,
<br /> responsible Ecr the 142x , The responsible party would normally be the tank ;
<br /> owner. r RE1DIP,L ACMON i r
<br /> . } Indicate which action`Yava beeTi used to cleanup or remediate the ieak.t 4
<br /> SITE LOCATION d ' /' Descriptions of options follow' �F
<br /> Ent,3 information regarding the tank foci"_ity. At a riini£aum, you mutt " +
<br /> ,r' Cap S.'.r. - ins tai:*hcriz rntal iwpermeabls layer to reduce.rainfal�'
<br /> provide theaTaeility namer and full address. r Ca -. f }
<br /> a infiltration, l 4- is
<br /> b •' .�- hT Containment Barrier"- install vertical dik to block horizontal4mavewent of
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<br /> IMPLEMENTING AGENCIES'-
<br /> Enter names of the 'oval agency and Rcgicnal-AAlter '�ualitg Contra]. Board contaminant. 1 �
<br /> involved, Excavate and Dispose - remove contaminated soil and dispose in approved
<br /> site,
<br /> SUBSTANCES ITiVOfVE? r Excavate and Treat - remove contaminated soil and treat (includes sprE�Oing
<br /> Enter the name and quantity Lost,.of the para Tu s eubstancg involve r d n nr nd fa-niingl. , I
<br /> is uzovided for in+ox�nation.>an't6 substance s'if appropriate. If mare tian Re�eovu Free Product -- remove floating product from water gable.
<br /> ' two substatcs�lleakad, list the two of ¢est 8pncern £or cleanup. 4 Pump and Treat Groundwater - generaLly employed to remove dis.vi ad f
<br /> contaminants.
<br /> DIS C`vETZY/ABA`Ir3 NT a'j A i' + Enhanced P,ia e radatioxi - use of any available tQchnology to pwvmote
<br /> Provide in£armaticn rggard, the,discovery and sbatementfof the leak_ hacteraal decomposition e£ ccntanl a�yts.
<br /> Replace Supply - provide alternative water supply to affected ��rt,�es.��
<br /> SOi.TRCE/CAUSE �� Treatment atfiioaku - install water treatment devices at each ii�-Liin& or
<br /> Indicate sour�L(s) f leak. Check bo k'esi indicatWng taus® of If:ak. other place of use.
<br /> I a w' Vacuum Fxtra�at - use pumps or blowers to draw air through sol !� k
<br /> _ CASE '"yP # k �j reit?; Snit --re holes in soil to A,low volatilization of.=contaminilits.
<br /> " Indicate the cdse iype ;categtFrY Edr GhiS'leak. Check one ox only. C,14 No Action Fsguired - incident s aanaz, zequiriY? �1n rem d�a1 ac,tign.°y
<br /> type �s base _I
<br /> the mast s"e5sitive resource affec'.;ed. F example, if (Q
<br /> both soil and�j�iouna'water have been affected, case type will.be "Ground? CCMMENTS - UWe this space to elaborate an any aspects of the in id�t,.
<br /> Water". Ind'icy-e "Drinl�in�_. ater" aniy if one or more municipal or ,*,if + r�
<br /> domestic water wellsilave actually been affected. A "Ground Water" Y"'� SIGNATURE - Sign the form in the space provided.
<br /> designation does not, {n iy that ttze affected mater cannot be, or is not,
<br /> us�:d for drinking water, hut, only tnat water wells have n�j yet heun DISTRIBUTION si
<br /> affected.,_ It is under toad that case type m4y change u;lon-further I£ the form is completed by the tangy o�ner az his agent, retain themei "I u`nlry
<br /> investigations. and forward the remaining copies intact,to your local perms i g - envy
<br /> +�+ • # "�. f'
<br /> for distribution.
<br /> CURRENT STATUSr+�- f I. Ozibiztel Local Tacik Permitting agency f*
<br /> Indicate the ate ory,tyhich best des^.rikes the warrent status of the ca e. 2. State ester Resources Control Boairdl. Division o£ Clean Water Pkog'rams,
<br /> Check one iso* only, the response shou]„,-j ba elative to the case type.'�=or Underground Stoxage'Tank Program, P.O. Box.:944212,, S.acramen�p*�C<J4244-
<br /> example if r�i e tyu"�F s "Ground Water_Xla ,Current Shur" should jgfer F - 2120 r
<br /> to .the statuslof the ground water invos,4y;atlot) pr clea i, as oppalaed4 0 3. Regional Water {Quality Control Board 1 `
<br /> • that al nail ascr tons of options 11 4. ,. ,oval Health Officer.and Cauc=ty Board of Supervpsors or them.d s at
<br /> j receive Propos ilon'S5 notifications.
<br /> 5 :da Actiari'Taken - No actiar€ has bee�ja��i�by xespon��l.e party bey�fid 5, ;� responsible party.
<br /> initial r,?port of leak. '
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