UAR/PROP 65 PRE 2019 - Laserfiche WebLink

Home Browse Search

W c w INSTRUCTIONS EMERGENCY CURRENT STATUS Indicate whether emergency response personnel and equipment were involved at nal Cate t e category which best describes the current status of the case. any time, if so, a Hazardous Material Incident Report should be filed with Check one box only. The response should be relative to the case type. For the State Office of Emergency Services (GES) at 2800 Meadowview Road, example, if case type is "Ground Nater", then "Current Status" should refer to Sacramento, CA 95832. Copies of the DES report form may be obtained at your the status of the ground water investigation or cleanup, as opposed to that of local underground sterane tank permitting agency. Indicate whether the DES soil, report has been filed as of the date of this report. 114PORTANT: THE INFORMATION PROVIDED ON THIS FORM IS INTENDED FOR GENERAL LOCAL AGENCY ONLY STATISTICAL PURPOSES ONLY AND IS NOT TO DE CONSTRUED AS REPRESENTING THE -TO va gid duplicate notification pursuant to Health and Safety Code .Section OFFICIAL POSITION OF ANY GOVERNMENTAL AGENCY 25180.1, a designated government employee should sign and date the form in i, this block. A signature here does not mean that the leak has been determined REMEDIAL ACTION to pose a significant threat to Fuman health or safety, only that notification Trd cate whicractions have been used to cleanup or remediate the leak. procedures have been followed If required. Descriptions of options follow: REPORTED BY Can Site - install horizontal impermeable layer to reduce rainfall n� ter your name, telephone number, and address_ Indicate which party you Tni tration. represent and provide company or agency name. Containment Barrier - install vertical dike to block horizontal movement af`-con taTantt RESPONSIBLE PARTY Excavate and Dispose - remove contaminated soil and dispose in approved E'.nter name, telephone number, contact person, and address of the party site: responsible for the leak. The responsible party would normally be the tank Excavate and Treat - remove contaminated soil and treat (includes Owner. sprea ing or and farming). ta—FT Free Product - remove floating product from water SITc LOCATION -FT ---- En Ler nnio_m»tion regarding the tank facility and surrounding area. At a PP�umpp�__and��Treat Groundwater - generally employed to remove dissolved minimum, you most provide the facility now and full address. contaminan[s. Enhanced Biodegradation - use of any available technology to promote IMPLEMENTING AGENCIES bacteria ecomposition of contaminant, toter names o the gcei agency and Regional 'dater Quality Control @pard ReQlace Sup ly - provide alternative water supply to affected Involved. parties. Treatment at Hookup - install water treatment devices each dwelling or SUBSTANCES INVOLVED of er p ace ct use. Toter the name in guan ti ty lost of the hazardous substance involved. Room is No ActionRe u�ired _ incident is minor, requiring no _ provided for information on two substances 1f appropriate. If more than tyro reme�tign. substances leaked, list the two of most concern for cleanup. COMMENTS - Use this space to elaborate on any aspects of the incident. OI SLOVERYIADATEMENT 3TWA?ilRE - Sign the form in the space provided. Provideir,T(Trmation regarding the discovery and abatement of the leak. UIS _TT=ON SOURCE?CAUSE If the form is completed by the tank owner or his agent, retain the last copy n7 dtcatsourcefs) of leak. Provide details on tank age: capacity and and forward the remaining copies in tact to.your local tank permitting agency - material if known. Check boxfes) indicating cause of leak. for distribution. 1. Original - Local Tank Permitting Agency CASE TYPE 2. State Water Resources Control Board, Division of Nater Quality, Tndncatthe case type category for this teak. Check one box only. Case type - Underground Tank Program, P. 0, Box 100, Sacramento, CA 95801 is based on the most sensitive resource affected. For example, if both soil 3. Regional Water Quality Control Board and mroued water have been affected, case type will be "Ground dater". - 4. County Board of Supervisors or designee to receive Proposition 65 _ lr,dicate "Drinking Water" only if one or more municipal or domestic water notifications. wells have actually been offect.rd. A "Ground Nater" designation does not 5. Owner/responsible party. imply that the affected water cannot be, or is not, used for drinking water, Out Only that water wells have not yet been affected. it is understood that case type may charge upon further investigation.