SITE INFORMATION AND CORRESPONDENCE

Home Browse Search

INSTRUgTIONS EMERGENCY Indicate whether emergency response personnel and equipment were involved Preliminary Site Assessment Workplan Submitted - workplan/proposal at any time. If so, a Dazardous Material Incident Repqrt should be, filed requested of/submitted by responsible party to determine whether ground with the State Office of Emergency Se vices (OES) at 260(1 Meadowview'Road, water has been, or will be, impacted as a result of the release. Sacramento, CA 95832. Copies of the OES report form may be obtained at Preliminary Site Assessment Underway - implementation of workplan. 1% your local undergrpund storage tank'1iermitting agency. ;Indicate whether Pollution Characterization - responsible party is in the process of fully the OES report has been filed as of the date of this report. defining the extent of contamination in soil and ground water and assessing impacts on surface and/or ground water. LOCAL AGENCY ONLY Remediation Plan - remediation plan submitted evaluating long term To avoid duplicate notification pursuant to Health and Safety code Section remediation options. Proposal and implementation schedule for appropriate 25180.7, a designated government employee should sign edid date the form-in remediation options also submitted. this block. A signature here does not mean that the leak has been Cleanup Underway - implementation of remediation plan. determined to pose a sigfSificant thFeat to human health or safety, only Post CleanupMonitoringin Progress - periodic ground water or other that notification procedures have been followed if required. monitor. ng at site, as necessary, to verify and/or evaluate effectiveness of remedial activities. REPORTED BY Case Closed - regional board and Local agen6y in concurrence than no Enter your name, telephone number, and address. Indicate which party yoti,- further work is necessary at the site. represent and provide company or agency name. IMPORTANT: THE INFQRMATION PROVIDED ON THIS FORM IS INTENDED FOR GENERAL RESPONSIBLE PARTY STATISTICAL PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REPRESENT ING,THE Enter name, telephone number, contact person, and address of the party 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 remediate the leak. SITE LOCA'!!! / `• Descriptions of options follow: Enter info m tion regarding the tank facili�y. At a minimum, you must 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 Water 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 involved. Room or land farming). > , ., natio;, ,n'..0o substances if appropriate. If more thhn Remove Free Product - remove floating product from water table. t,wo substances Leaked,'list the two of most concern for cleanup. Pump and Treat Groundwater - generally employed to remr a dissolved r contaminants. DISCOVERY/ABATEMENT Enhanced-Biodegradation - use of anv AvRilAblo t.prhnnln¢v t.n nrmmnta Provide information regarding the discovery and abatement of the Leak bacter e•1 decomposition of contaminants Replace Supply - provide alternative water supply to affected parties. ` SOURCE/CAUSE r Treatment at Hookup - install water treatment devices at each dwelling or 1 Indicate source(s) of"leak. Cjieck r+oxies) indicating cause of leak. other place of use. Vacuum Extract - use pumps or blowers to draw air through soil. CASE TYPE �� J Vent Soil -- bore holes in soil to allow volatilization of contaminants. Indicate the case type category for'this leak. Check one bo$•�only. Case- No Action Required - incident is minor, requiring no remedial action. type is based ov the most sensitive resource affected. For example, if both soil and gfound water have been affected, case type will be "Ground COMMENTS - Use this space to elaborate on any aspects of the incidefit. Water". Indicate "Drinking Water" only if one or more municipal or domestic water wells haye actually been affected. A "Ground Water" SIGNATURE,--Sign the form in the space provided. designation does not imply that the affected water cannot be, or is not, used for drinkiag water, but only that water wells have not yet been DISTRIBUTIr affected. It is understood that case type may change upon further If the form is completed by the tank owner or his agent, retain the fast copy investigation.' and forward the remaining copies intact to your Local tank permitting agency for distribution. CURRENT STATUS 1. Original - Local Tank Permitting Agency Indicate the category which bestd_RseTibes the current status^of the case. 2. State Water Resources Control Board, Division of Loans and Grants, Check one box gnty, Thit respont should be relative to the case type. Foi Underground Storage Tank Program, P.O. Box 944212, Sacramento, CA 94244- example, if case type is "Ground Water", then "Current Statug" should refer 2120 to the status of the ground water investigation or cleanup, as, opposed to '3. Regional Water Quality Control Board that of soil. Descriptions of options follow: 4. County Board of Supervisors or designee to receive Proposition 65 l notifj,cations. No Action Yaken - No action has•been taken by responsible party beyond _. Owner/,responsible party. initial report of Leak. Leak Being Confirmed - Leak suspected at site, but has not been confirmed. r