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INSTRUCTIONS=
<br /> rFMERGENCY Leak Being,, Conf rmed - I,,eak suspected t sitebut has not been .onl.irmed.
<br /> Indicate whether emergency 4ponse persaxnnel and equipment were i"izvo_.>ed Preliminary Site As=essmenwu kolan Submitted - workplan/prop-
<br /> at any time. If so, a Raza:rdcus Material ncident Rep-,.,rt should be filed requested of/submitted by resporislible, party to determine w ethround
<br /> with the State Officr, of Emergency Services (OE,S) at;-2300 Meacicarriew Road, water :ha been,'or will bp, imm,.:ct d a� a result oP the rel e ;t(;
<br /> Sacramepto, CA 95832 Copies of the CES report farm may he obtained at Pr.eli: inarr Site Assass:nc;n` derr.aw - implemontati,on a cork
<br /> your local underground storage tank permitting agency. Indicate wl:ethr Prall.i.tion Chracterir,ation r ,nsibe panty s in `ne ra ' f fully
<br /> the OES report has been filed as of the date of this report. - defining the extent of contamination to soil and ;round aater�� asaes Wr:g
<br /> i:upactz onrface and/or grt _i water. >kj
<br /> I.CCAL AGENCY O`TLY Ramediar n 'lan - remediation plan submitted evalua g 1011, w�*m
<br /> To avoid duplicate notification pursuant to'Health and Safety Tole Section remediation options. Proposal and Implementation _chedul.e for appropriate
<br /> 25180,5, a governtnzent ems^''oyee'should sign and date the form in this block. remediation options also submitted.
<br /> A signature here does riot mean that the leak has been determined to pose a Cleanup Lnderwav - implementation of remediation plan.
<br /> significant threat to hirnax health or safety, only that notification Post Cleanup Monitoring in Progress periodic ground water or other
<br /> procedures have been followed if required. monitoring at site, as necessary, to verify and/or evaluate effectiveness
<br /> a remedial activittgs.
<br /> REPORTED BY Case Closed - regional board and Local agency .in concurrence that no
<br /> Enter your name, telephone number, and address. Indicate which party you further work is necessary at the site.
<br /> 6SPONSIBLE
<br /> pr.esent and provide company or agency nacre.
<br /> IMPCRTAN� : THE INFOR-IATION PROVIDED CN THIS FORM IS INTENDED FOR GENERAL PARTY
<br /> STATISTICAL P'UTRPOSES 017'Y AND IS NOT TO 3E CONSTRUED AS REPRESENTING THE
<br /> Enter name, telephone slumber, contact person, and address of the party O"FFICIAd, POSITION OF ANY GOItERNMENTAL AGENCY
<br /> responsible for the lea<. The responsible party would ;normally be ttze tank
<br /> owner. REMEDIAL ACTION
<br /> Indicate which action have been used to Cleanup or remediate the leak.
<br /> SITE LOCATION Descriptions of options follow:
<br /> Enter i.n'fo.rmaton regarding the tank facility. At a min.im.n, you must
<br /> provide the facility name and full address. Cal) Site - install horizontal impermeable layer to reduce rainfall
<br /> infiltration.
<br /> IM.PLEMENTTNG AGENCIES Catai.nme;nt Barrier - install vertical dike to black horizontal mavemexit of`
<br /> Enter nsnaes of the local agency and Regional ;nate:: Quality Control Board contaminant.
<br /> involved. Ex av ate and Dispose - remove cortataxnated soi-I and dispose in apl oveci
<br /> site.
<br /> SUBSTANCES IN_V0L1-,D E}cavate and Treat - remove con'amiratee soil and treat (includes spreading
<br /> Enter the name and quantity lost of the hazardous substance i;.noolved. Rooth or land farming).
<br /> is provided for information on,two substances if appropriate. If more than Remove Free Product - romovc floating product from water table.,
<br /> two substances leaked, list the two-of most concern for cleanup, Pw^m and Treat Groundwater - generally employed to remove dissolved°
<br /> contam.inar;tz,
<br /> DISCCVERY/ABATEMENT 'Enhanced ,noderaradatic?xn - use of any ava.lable technology to promote
<br /> Provide information regarding the discovery and (nlatrmeizt of the Leak. _.cteriadecomposition of co:.tar.nan.ts.
<br /> R -ace Su)s;ls° - provide alternative water supply to affected partes.
<br /> SOURCE/CAUSE_ eatment at i_�ookun install water treatment devices at each dwelling or
<br /> Indicate sources) of leak. Check box(es) .indic'6ting cause of leak. other place of use.
<br /> Vacuum Extract - use pumps or blowers to draw air through soil:.
<br /> ASE TYPE, Vent Sai'. - bare holes in soil to allow volatilization of contaminants:
<br /> �tdicete the case type category for 'this leak. Check one box only. Case No 6--tion Reclui.redR r.incident is mino , requiring no remedial. action,
<br /> type is based on the molt sensitive resource affec-ed. For example, if
<br /> both soil. and ground water have been affected, case type will,be "Ground CM-7,NTS - Use this space to elaborate on any aspects of the incident.
<br /> Water". Indicate `:;rixnlsing Water" only if one or more murnci.pa- or
<br /> domestic water ,cells have actually been affected. A "Ground Water" SIGN.LRTE - Sign the form in the space.provided.
<br /> designation does not im.ply that the affected water cannot be, or is ;not,
<br /> used for drinking water, but only that water wells have not yet been
<br /> 09
<br /> affected. It is understood that case type may change upon furtt:cr t form is completed by the tank owner or his agent, retain the la5l. rc
<br /> investigation. and fi.f l" tine remaining copies intact to your .oca: tank pert_z_trzg ag<.n,.
<br /> for . t-_J cil,
<br /> CURRENT STATUS It 1. OriglnaLorcal Tank Permitting Agen y
<br /> Indicate ttae category which best describes the cu.•r
<br /> : ent
<br /> t status of tine 'case. L. teha resources Control Board, Divizl.>n of C'_ean Water Pr g am ;
<br /> Check ohne Sax only. The response should ,e ,...la-.,i.ve to the case type, Fra na:r rr,... 6 Storage Tank Program, P.O. Ea; 4.:17., aarsnme;nta, v._-9444-
<br /> example,
<br /> 9 2,aLe•xampl.e, if case type is "Ground Water'., ..::.en "Current Status", shc3uld refer 2a.2i.
<br /> to the status of txze ground wager .invest-=,.zticn -or c �anup. opposed to 3, 12.-g_ct.a :{.er Quality Control Board
<br /> that. of soil. Descriptions of options foL ow- 4, Local Offif;cr and CQUInt,7 .;card of Sui . ..n..._'rs n: th.,,,, e.,z);t_ea t.;:
<br /> N,:) Actiomactic)nn has been taken by responsible p._tv beyond `.i, n ,., }:t:le party
<br /> „_ ak.
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