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INSTRUCTIONS EMERGENCY CURRENT STATUS indicate whether emergency response personnel and equipment were involved at Indicate the 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 (DES) at 2800 Meadowview Road, example, if case type is "Ground dater", then "Current Status" should refer to Sacramento, CA 95832, Copies of the OES report form may be obtained at youl the status of the ground water investigation or cleanup, as opposed to that of local underground storage tank permitting agency. indicate whether the DES soil. report has been filed as of the date of this report. IMPORTANT: THE INFORMATION PROVIDED ON THIS FORM IS iNTENDEu FOR GENERAL LOCAL AGENCY ONLY STATISTICAL PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REPRESENTING THE To avoid duplicate notification pursuant to Health and Safety Code Section OFFICIAL POSITION OF ANY GOVERNMENTAL AGENCY 25180.7, a designated government employee should sign and date the form in this block. A signature here does not mean that the leak has been determined REMEDIAL ACTION to pose a significant threat to human health or safety, only that notification n icate wFic+Factions have been used to cleanup or remediate the leak. procedures have been followed if required. Descriptions of options follow: REPORTED BY Cap Site - install horizontal impermeable layer to reduce rainfall Enter your name, telephone number, and address. Indicate which party you infiltration. represent and provide company or agency name. Containment Barrier - install vertical dike to block horizontal movement o? contaialnant. — RESPONSIBLE PARTY Excavate and Dispose - remove contaminated soil and dispose in approved Flit-rn.m=,r 1epc� onrt fersoe, and address of the party ax z 3,3+ty would normally be the tank Excavate and Treat - remove contaminated soil and treat ;includes spreading or land farming). Remove Free Product - remove floating product from water SITE LOCATION' table. -- EnTer information regarding the tank facility and surrounding area. At a Pump and Treat Groundwater - generally employed to remove dissolved minimum, you must provide the facility name and full address, contain-inants. Enhanced Diode radation - use of any available technology to promote II PLEMEF.TING AGENCIES bacterra�decaarpos�tion of contaminants. Enter nares of�hcocal agency and Regional Mater Duality Control Board Replace Supply - provide alternative water supply to affected involved. parties. Treatiaent at Hooker - install water treatment devices at each dwelling or SUBSTANCES INVOLVED other place Entc-r the nano and quantity last of the hazardous substance involved. Room is No Action Required_ - incident is minor, requiring no %9 provided for information on two substances if appropriate. if more than two namedial action. substances leaked, list the two of most concern for cleanup. COMMENTS - Use this space to elaborate an any aspects of the incident. DISCOVERYIARATEMENT 7GNA7URE - Sign the form in the space provided. ProvF inforrr;anion regarding the discovery and abatement of the leak. DISTRIBUTION SOURCE%CAUSE If the form is completed by the tank owner or his agent, retain the last copy Indicate source(s) of leak. Provide details on tank age; capacity and and.forward the remaining copies in tact to your local tank permitting agency mate r al if known. Check 1"x(es) indicating cause of leak. for distribution. 1. Original - Local Tank Permitting Agency CASE TYPE 2. State Water Resources Control Board, Division of pater Duality, I drea*r—the case type category for this leak. Check one box only. Case type Underground Tank Program, P. 0. Box 100, Sacramento, CA 96801 i; based on the most sensitive resource affected. For example, if both soil 3. Regional Water Quality Control Board and g?-ound water have been affected, case type will be "Ground Water". 4. County Board of Supervisors or designee to receive Proposition 65 :ndicate "Drinking Water" only if one or more municipal or domestic water notifications. weds have actually been affected. A "Ground Wa'ter`� designation does not 5. Owner/responsible party. imply that the affected 'water cannot be, or is not, used for drinking water, but only that water wells have not yet been affected. It is understood that case type may change upon further investigation.