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THST.
<br />RL29P
<br />EMERGENCY `
<br />Laak BeingConfired -Leah suspected at site, but has not been -confirmed.'
<br />Indicate wh,other emergency response•personnei and e uipz.-aaent were involved
<br />PreLim nary Site Assessment S�orkTalan Submitted - workplan/proposal
<br />at any time. If -so, a hazardous Materiae Incident Report should be filed
<br />requested of/submitted by responsible party to determine whether ground`'" "
<br />with t e.'State Office of Emergency Sere®des 'C7--5) at 2800 meacowview Road,
<br />water has been, or will be, impacted as a result of the release. '
<br />Sacramento, CA 95832. Copies of the ETES report form may be obtained at
<br />Preliminary Site Assessment inderwav - umplamentation of workplan.'
<br />your .'Local underground storage tank permitting agency. Indicate whether
<br />Pollution Characterization - responsible party is in;the Process of fully
<br />the CES report has been filed as of The date of this report,
<br />defining the extent of contaminatjon in, soil and ground avatar and assessing
<br />SUBSTANCES INVOLVED y
<br />impacts ora 'surface and%ear ground water.
<br />L{ AL ACIF.NCY Ctv' Y
<br />Remediation Flan -:remediation plan submitted evaluating Long Term
<br />To avoid duplicate notification pursuant to health and Safety code Section
<br />remediatiou options. Proposal and implementation schedule for appropriate
<br />25180.5, a government employee should sign and date the fora in tlhis bock.
<br />remediation options also submitted.
<br />A signet re here does not mean that the Teak has beer. determined to pose i'
<br />Cleanuo Underway -'implementation of remediation plan.
<br />significant threat to human "health or safety, only that notification
<br />Post, Cleanup Monitoring in Pro -res- - periodic ground water or other
<br />procedures` have been followed if required.
<br />monitoring at site:, as necessary, to verify and/or evaluate effectiveness
<br />SOURCE/CAUSE
<br />of
<br />of remedial activities.
<br />REPORTED BY
<br />Enter 'address.
<br />4
<br />Closed'- regional board and Local agency in concurrence that 'to
<br />your name," telephone number, and Indicate which party you
<br />further.work is necessary at the site,
<br />represent and provide company or agency name,
<br />RESE2NSIBLE PARTY
<br />IMPORTANT: THE* INFORMATION PROVIDED ON THIS FORM IS INTENDED FOR GENERAL
<br />type is based --=an the most sensitive resource affected. For .example, if
<br />STATISTICAL F GSES ONLY AND IS NOT TO BE CONSTRUED AS REPRESENTING THE`,
<br />Enter name telephone number, contact person, and address cif -the party
<br />OFFICIAL POSITION OF ANY GOVERNMENTAL AGENCY
<br />responsible for 'the leak. The responsible party would normally be"the tank
<br />owner.
<br />RL29P
<br />Indic
<br />SITE LOCAT2t3N'
<br />Enter information 'regarding, the tank facility. t a minimum, I you mast
<br />provide the facility name and full address:
<br />C
<br />IMELEiMENTING AGENCIES
<br />a
<br />C
<br />Enter names of the local agency :and Regional Water Quality Control Board
<br />c
<br />involved.
<br />E
<br />SUBSTANCES INVOLVED y
<br />s
<br />E
<br />Enter the .ame and q aitity lost of the hazardous substance involved. Boom
<br />o
<br />IS provided for information on two substances if"appropriate. If more than
<br />R
<br />two substances leaked, list tae two of most concern for cleanup,
<br />P
<br />DISCC1VIMZABAT IdT
<br />c
<br />E
<br />Provide inforization regarding the discovery and abatement of the Lear,
<br />b
<br />R
<br />SOURCE/CAUSE
<br />T
<br />Indicate soulce(s) of Teak.. Check boxes} indicating cause of leak.
<br />a
<br />.
<br />V
<br />CASE TYPE
<br />Indicate the -case type: category for this leak. Check one box only. Case
<br />type is based --=an the most sensitive resource affected. For .example, if
<br />both soil ana:;ground"water have been affected, case type will be "Ground
<br />COt4jEl
<br />Water". Indicate " Drinkir:g beater" only if one or more municipal or
<br />domestic water wells have actually been affected. A "Ground Water"'
<br />SIGN&
<br />designation does not imply that the affected seater cannot be or is not,
<br />used: for drinking €nater, but only that ester wells have not yet been
<br />i3I>TR;
<br />affected. It is understood that case type may change '`upon farther
<br />If vita
<br />investigation.
<br />and fs
<br />for di
<br />a
<br />CURRENT ENT sTATus
<br />1. O.
<br />Indicate the category which best describes the current status of the case,
<br />2. S'
<br />Check one box only. The response should he relative to the case type. Fox
<br />U
<br />example, if case type is "Ground Water", then "Current Status" should refer;
<br />2;
<br />to the stands of the ground water investigation or cleanup, as opposed to
<br />3. Ro
<br />that of soil. ._pescriptions of options follow:-
<br />4 Is
<br />No -Action: !r ken - No action has been taken by responsible party beyond +
<br />rs
<br />5. 0...
<br />initial report. of leak. `
<br />ACTION:
<br />a which action have been used to cleanup or remediate the Leak.
<br />;ions of, options follow:
<br />Site - install horizontal impermeable layer to reduce rainfall
<br />�ltratioxz.
<br />sainment Barrier _ install vertical dike to block horizontal movement of
<br />;aminant
<br />ovate and L2isxsose -,remove contaminated soil and dispose in *'approved '
<br />ivate and Treat - remove contaminated soil;and.treat (includes spreading
<br />Wand farming),
<br />7ye Free Product - remove floating product from '}rater table,.
<br />z and Treat —Groundwater - generally employed to remove dissolved
<br />:aminants.
<br />€aced Biodegradation -'use of any available technology to promote
<br />erial decomposition of otntaminants.
<br />doe Supply - provide alternative crater
<br />-supply to affected parties.
<br />Etment at Hookup - install water treatment devices at each dwelling or
<br />:r place of use.
<br />tum Extract - use pumps or blowers to draw air through soil. ...
<br />, Soil — bore holes in soil to allow volatilization of contagainants.
<br />:etion RIggi.r.ed - incident is minor, requiring no remedial,action.
<br />i
<br />- Use this space to elaborate on any aspects of tae incident,
<br />= Sign the form in the space provided.
<br />ION
<br />ormi is completed by the tank owner or his agent, retain the lost copy'
<br />and the remaining copies intact to your local t , permitting agency.
<br />rib stion,
<br />incl - Local Tank Permitting Agency
<br />P Water Resources Control Hoard, Division of Clean Water Programs,
<br />rground Storage, Tank Program„ P.O. Box 944222, Sacramento; CA 94244-
<br />anal boater Quality Control Board
<br />I Health officer and County Board of Supervisors or their designee to
<br />ive Proposition 65 notifications,
<br />r/responsible partly.
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