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INSTRUCTIONS
<br /> ErA*FRGENCY Loak Being Confirmed - Leak suspected at site, buthasnot been confirmed.
<br /> Indicate whether emergency response personnel and equipment were involved Preliminary Site Assessment Workplan Submitted - workplan/proposal
<br /> at any tuna. If so, a Hazardous Material. Incident Report should be filed requested of/submitted by responsible party to determine whether ground
<br /> 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.
<br /> Sacramento, CA 95832. Copies of the CES report firm may be obtained at P.a iminary Site Assessment Uhiderwav - iipleme tation of workplan.
<br /> your local.urderground storage tank permitting agency. Indicate whether Follution Characterization - resnonsible party is in the process of fully
<br /> the OES repo•;, has bees filed as of the date of this report, defining the extent of contamination in soil and ground water and assessing
<br /> impacts on surface arid/or ground water,
<br /> LOCAL AGENCY ONLY - F mer at`.on Pan - remediation plan submitted evaluating long term
<br /> To avoid dull cate notification pursuant to Health and Safety code Section remediation options. Proposal and implementatirn schedule for appropriate
<br /> 25180.5, a government employee should sign and date the form in this block. remediation options also submitted.
<br /> A signature here odes not mean that the leak has been determined to pose a Cleanup Underway - implementation of remediation plan.
<br /> significant threat, to human 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 /> of remedial activities.
<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 /> present and provide company or agency name. ..
<br /> IMPORTANT: THE -INFORMATION PROVIDED ON THIS FOlel IS INTENDED FOR GENERAL,
<br /> VESPON�,TBLF"PAR'TY STATISTICAL PMPOSES ONLY AND IS NOT TO BE CONSTRUED AS REPRESENTING TEE
<br /> Enter name, telephone number, contact person, and address of the party OFFICIAL POSITION OF Ad3Y GOVERNMENTAL AGENCY
<br /> responsible for the leak. The responsible party would normally be the tank
<br /> owner. .REMEDIAL ACTION
<br /> Ind tate which action have been used to cleanup:;or. remediate the leak.
<br /> SITE LOCATION Descriptions of options fallow:
<br /> Enter information regarding the tank facility. At a minimum, you must
<br /> provide the facility name and full address. Cars Site - install horizontal impermeable layer to reduce rainfall
<br /> infiltration.
<br /> IMPLEMENTING AGENCIES Co- to nment Barrier - install 'vertical dike to block horizontal, movement of
<br /> Enter names of ttie local agency and Regional Wate;: Quality Control Board contaminant.
<br /> involved, E cavato and Dispose - remove contaminated soil and dispose in approved
<br /> si-
<br /> e
<br /> SUBSTANCES 1NV:OLVJD Excavate and Treat - remove contaminated soil. and treat (includes spreading
<br /> Enter the r€arae and quantity lost of the hazardous substance Involved. :Room o. land farming).
<br /> is provided for information on two substances if appropriate. If more than Remove Free Product remove floating product from water table.
<br /> two substances leaked, fist the two of most concern for cleanup, kgmo and Treat Groundwater - generally employed to remove dissolved
<br /> cort<�m�nants.
<br /> DISCOVERY/ABAJEM%NT Biodegradation - use of azsy available technology to promote
<br /> Provide _nformat on .regarding the discovery and abatement of the leak. b_,cteil..•.. decomposition of contaminants.
<br /> provide alternative water supply to affected parties.
<br /> 50ttRC5/GAJ r, pertat ookur. install water treatment devices at each dwelling r
<br /> *'SE
<br /> dicate source{s) of leak. Check boxes) 'indicating cause of leak. o c 1- of use.
<br /> Va z x* act - use pumps orblowers to draw air through soil.
<br /> TYPE _.,t Sci bore '-soles in soil to allow volatilization of contaminants.
<br /> Indicate the case type category for this leak. Check one box only. Case- NG Action Required - incident is minor, requiring no remedial action.
<br /> type is based on the most sensitive .resource affec'ued. For example, .if
<br /> bona soil and ground water have been affected, case type will be "Ground COc3 Et;TS - Use this space to elabo ata on any aspects of the incident.
<br /> Water". Indicate "Drinking Water" only if one or more municipal or
<br /> domestic water wells have actually been affected. A "G:-ound Water" SIGNATURE - Sign the form in the space provided.
<br /> desil rataoa co.es not imply that the affected :tater cannot be or is riot,
<br /> used fat Ir_rsk ng water, but only that water wells have not yet: been DISTRI11U1,ION
<br /> affected it is understood that case type may change upon further If the .form is:completed by the tank owner or 1-is areut, retain the last ec1y
<br /> iu✓estiga Tann and forwlyd t£e remaining copies intact to your .oci tank permitting agency
<br /> for
<br /> C€J RENTi TU'S4 1. O g..,.l - Local Tank Permitting Agency
<br /> Ind ::at thz r. te,o.ry which best describes the current status of the case. 2. S.,.t._ Watez Resources Control Board, Division of. Clear: Water Programs;
<br /> Ctark one oh The response should be, r lative to the case tyre. For Und rou€ Storage Tank Program. P C 9444;1
<br /> x a �, g i,ax 2, 5-:;;ramento, Cr. 96244-4
<br /> exampleill , yi "Ground
<br /> Wattr than 'CurrentStatus" - er 21 +
<br /> to t€e of s roundnvosigatiori
<br /> or cleanup. a,, cjppos d 3. R Water Qu..,_-ity Control Bc)ard
<br /> tk,at of w,:i._ p y „ __ their designee _.
<br /> ,.
<br /> 2es �-in?;ions of options £e:l.ew: ...�.�- a�><..t._ Offi..e, and C,�unt-=x Board of Su l. r` .
<br /> 65 notificat ions.
<br /> 2.n e ,,.•<,. � No action has beat, taken by reseons;'Hle party b.=_v:�.r� �. �* _ .- _ .�a;l _ :ray. -.
<br /> ofl :ak.
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