UAR/PROP 65_PRE 2019 - Laserfiche WebLink

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' INSTRUCTIONS EMERGENCY Leak Being Confirmed - Leak suspected at site; but has not been confirmed. Indicate whether emergency response TLersonnel and equipment were involved- Preliminary Site Assessment Workplan Submitted - workpl..an/p.roposal at any time. If so, a Hazardous Material. Incident Report should be filed requested of/submitted 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. Copies of the OES report form may be obtained at Preliminary Site Assessment Urderwav - implementation of workplan. your local. underground storage tank_ermitting 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 25180.5, a govermnent employee should sign-and date the form in this block. remediation options also submitted. A signature here does not mean that the leak has been determined to pose a Cleanup Underway - implementation of remediation plan. significant threat to human health or safety• only that notification Post Cleanup Monitoring in Progress - periodic ground water or other procedures have been followed if required: monitoring at site, as necessary, to verify and/or evaluate effectiveness of remedial. activities. REPORTED BY Case Closed - regional board and local agency in concurrence that no Enter your name, telephone number, and address. Indicate which party you..- further work is necessary at the site. Ge,present and provide company or agency name. IMPORTANT: THE INFORMATION PROVIDED ON THIS FORM IS INTENDED FOR GENERAL -SPONSIBLE PARTY STATISTICAL PIRPOSES ONLY AND IS NOT TO BE COPISTRUED AS REPRESENTING THE Enter name, telephone number, contact_person, and address of the party OFFICIAL POSITION OF ANY.GOVERNMENTA? 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 LOCATION Descriptions of options follow: Enter information regarding the tank facility. 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. Wate* Quality Control Beard contaminant. involved. _ Excavate and Dispose - remove contaminated soil and dispose in approved site. SUBSTANCES INVOLVED Excavate and Treat - remove contaminated soil and treat (includes spread'ng Enter the name and auantity lost of the hazardous substance involved. Room or land farming). is provided for information on'two substances if appropriate. If more 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 cortam,nants. - DISCOVERY/ABAT€t-IZNT Enhanced Biodegradation - use of any availabi.e technology to promote Provide information regarding the discovery and.ahatement of__Lhe leak. bacteria! decomposition of contaminants. Replace Supply - provide alternative water supply to affected parties SOURCE/CAUSE Treatment at SookutZ- install water treatment devices at each dwelling or Indicate source(s) of Leak. Check box(es) 'Indicating cause of leak. other place of use. Vacuum Exiract - use pumps or blowers to draw air through soil. „E TYPE _ - Vent Sail - bore'holes in soil to allow volatilization of contaminants. indicate the case type category' for this leak. Check one bot only. Case No A.ct wn Required - incident is minor, requiring no remedial action. type is based on the most sensitive 'resource affec'ed. ,. For example, if - - both soil and ground water have been affected, case type will be 'Ground COI4,!ENTS - 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-h-ave actually been affected. A "Ground Water" SIGNATURE :Sign the form in the space provided. designation r'ces not imply that the affected water cannot be, or is net, used for drinking water, but only that water wells have not yet been DISTRIBUTION affected. It is understood that case type may change upon further If the form is completed by the tank o•nmer or his agent, retain the last ,copy in•✓estigation. and forward the remaining copies intact to your local tar:k permitting-agency for distribution. CURRENT STATUS - 1. Original Local Tank Permitting Agency Indicate the category which beat describes the ;rlrrent status of t:.e case.. 2. State water Resources Control Board, 'Division of Clean Water Programs, Check one box only. The response should be relative to,the case tvpe. Fox Underground Storage Tank Program. P.O. Bos 944312, Sacramento, CA-96244- example, if (upp- type is "Ground Water", then "Current Status" sho;ild refer %.120 to the _..:_fuss of the ground water investigation. or cleahup, as opposed to Regional Water Quality Control Board that of :soil- Descriotions of options fol-Low: Local Health Officer and County hoar.-! of Super! ors or their designee receive FrepositiDix L` notif c3t.ions. N^ Action T,%ce,) No actino,. bean taken by re:ponsi_ble patty 1,:1,.ri Ov>ner re:-ir,nsible party.