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INSTRUCTIONS
<br />UCTIONS
<br />EMERGENCY
<br />i,eak Beim Con�irried - Leak suspected at site, but has not been confirmed.
<br />Isadi^ate what bar emergency response personnel and equipment were involved
<br />Preliminarite Assessmen' or an Submitted - workplan/proposal
<br />at any time. If so �.a hazardous Material, Incident Report should be filed
<br />requested of submitted by responsible party to deterrx ne whether ground `
<br />with the State Offs of Eme genay Servfces (47ES) at 2800 Meadowview Road',`
<br />water has been, or will be impacted as a result of the release,
<br />Sacramento, CA 9584 Copies of the OES report form may be obtained at
<br />Preliminary Sate As�essyrezt anderwe - irplementav onlof workplan. =.
<br />your local undergro d storage tank permitting`aaganey. Indicate whether
<br />Pollcation Characterization - ;responsible party is in e process of fully
<br />the OES report has een filed as of the date of this report, defining the extent of con amination it soal and d assessing"
<br />p g rot .cF water a
<br />impacts on surface and/or ground water. =, .
<br />LOCAL AGENCY ONLY
<br />Remediation Plan - remediation plata submitted evaluating long tern
<br />To avoid duplicate notification pursuant to Iiealtta and Safety code Section
<br />remediation options. Proposal and implementation schedule for. appropriate
<br />25180,5, a government employee should sign and dale the formin this block.
<br />remediation options also submitted.
<br />A signature here doer: not mean that the leak has been determined to pose a
<br />Cleanse Underwav - implementation of remediation plan:
<br />significant threat to human health, or safety, only that notification
<br />Past-Cleanuxsi3onitoring in ?roress - periodic ground water or other
<br />procedures have been followed if required.
<br />at site, as necessary, to verify and/or evaluate effectiveness
<br />�monitoring
<br />of remedial activities.
<br />REPORTED BY
<br />Case Closed _ regional board and local t
<br />$ ..agency in Ci;tYCuS".e::nCe that no
<br />.. Enter your name, telephone number, and address, l'bdicate which party you
<br />further work is necessary at the site,
<br />eat and pr� irie Com. an or agency
<br />n p y g p name.
<br />I{fSPiIN�B_..,LEPART
<br />IMPORTANT. THE INFORMATION PROVIDED ON THIS FORM IS IN ,.E' LED FOR GENERAL
<br />I
<br />,.Ore
<br />STATISTICAL PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REPRESENTING THE
<br />Enter one numYer, contact person, and address of the party
<br />OFFICIAL POSITION OF Y GOV Nita, AGENCY
<br />xespone leak.. The responsible party would normally be the tank
<br />_.
<br />owner.
<br />, aqj- DIAL ACTION;
<br />Indicate which action have been used to cleanup or remediate the leak.
<br />SITE LOCATION
<br />Descriptions of options follow;
<br />Enter informati n regarding the t,ai.A facility. At a minimum, you must
<br />provide the facility name and full address.
<br />Cap Site - install horizontal impermeable layer to reduce rainfall
<br />infiltration.
<br />IMPLQENTING AGENCIES
<br />Containment Barrier - install vertical dike to black horizontal movement of
<br />Enter names of the local agency and Regional Water Quality Control Board
<br />contaminant,
<br />involved,
<br />`
<br />E2;cavate and Die se -- remove contaminated soil and dispose hi approved
<br />site.
<br />SUIiDTfaNCES I. OLaiED
<br />Excavate and Treat - remove contaminated soil and treat (includes spreading'
<br />Enter the na and quantity lost of thg hazardous substance involved. Room
<br />or land farming). ,
<br />is provided or information on two substances if apSropriate< If more than
<br />Remove Free ,Product - remove floating product Bora wat r table:
<br />two suhstan s leaked, list the two of most concern for cleanup,
<br />Pumis encs Treat Craundrater'- generally employed to recY ve dissolved
<br />contaminants'.
<br />DZSCO ERYIA TEP"ENT
<br />Enhanced Biodegradation - use of any available techroldgy to promote
<br />in ragaation regarding the discovery a%£i abatement £3f the leak <
<br />bacterial decomposition of contaminants,
<br />=Provide
<br />ReIaoe Sulanly provide alternative water supply to a fected parties. f
<br />CAU .;
<br />Treatment atIiookuti- install water tree went devices teach dwelling or
<br />Indicate source(s) of leak, Check box(es) indicating cause of leak:
<br />other' place of use.
<br />Vacuum Extract -,use pumps or blowers to draw air through soil,
<br />AGE TYPE
<br />Vent Soil - bore holes in soil to allow volatilization of contaminants,
<br />Indicate the case type category for this leak. Check one boat only, Case
<br />No Action Refraired - incident is mincer, requiring no temedfal action;
<br />type is based on the most sensitive resource affected. For example, if ,
<br />both soil and ground water have been affected, case type will be "Ground
<br />C NTS,- Use this space to elaborate on any aspects of the incident,
<br />Water", Indicate "Drinking Water" only, if one or more municipal or
<br />domestic water weals have actually been affected, A "Ground Water"
<br />SIGNATURE Sigh the form in the space provided.
<br />designation noes not imply that the affected water cannot be, or is not,
<br />used for drinking water, but only that water wells have not yet been
<br />DISTRIBUTION
<br />affect , It is understood that case type may change upon further
<br />If the farm is completed by the tank owner or his agent, retain the Last copy
<br />investr1kation.
<br />and forward the remaining copies intact to your local tank nermitting agency
<br />s
<br />CURREN STATUS
<br />for distribution. -
<br />I, Ctrigiraal -Local Tank Permitting
<br />t` Agency
<br />IndicAte the category which best describes the current status of the case ;` 2; State Water Resources Control, Board, Division of Clear evaue.- Programs,
<br />Check one box only. The response should be relative to the case type. For
<br />� Underground Storage Tank Program, P.O. Box 944212, Sacramento, CA 91,244 -
<br />example, if ease type is "Ground Water" then "Current Status'" should refer
<br />2120
<br />to the statics of the ground water investigation or cleanup, as apposed to
<br />3: Regional mater Quality Control Board
<br />that of soil: Descriptions of options follow-
<br />4. Local health Officer and County Board of Supervisors or their designee Lo
<br />-receive Proposition 55 notifications,
<br />No Action Taken - No action has been taken by responsible party beyond
<br />5, Owner/responsible party.
<br />Initial .report of Leak,
<br />
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