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(p� INSTRUCTIONS
<br /> x, Ec1ERGENCY Leak Being Confirmed - Leak suspected at site, but has not been confirmed.
<br /> Indicate wetter emergency response personnel and equipment were involved' Preliminar Site Assessment Flork San Submitted - workplan/proposal
<br /> at any time„ If stn, 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 Mea3owview. Road, water has been, or will be, impacted as a result of the release.
<br /> Sacramento, CA 958'=2, Copies of the CESS,report form may be obtained at P.reliminar Site Assessment Underpay - implementation of workplan,
<br /> your local underground storage tank permitting agency. 'Indicate whether Pollution Characterization - responsible party is in the process offully
<br /> the OES report has —,en filed as of the date of this report, defining the extant of contami:aticn in soil and ground water and assessing
<br /> : impacts on surface and/or ground water,
<br /> LOCAL AGENCY ONLY R mediation Plan - remediation plan L,sitted evaluating tong tern
<br /> Tc asT,_d dupI'race,notification pursuant to Health and Safety cote Sect on remediation options. Proposal, and implementation schedule for appropriate
<br /> 252€J.S, a government employee should sign and date the formin this bloolk, remediation options also submitted,
<br /> A signature here dries not mean that the leak, has been determined to ,posse a Cle,2�erway impimnentaticn: of remediation plan.
<br /> significant threat, to human health or safety, only that notification Post Cleanu Monitoring in P,-- - periodic Around nater 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 /> rater you? naeae telephone number, and address_ indicate which party you _ further work is necessary at the site,
<br /> represent and provide company or agency name.
<br /> IMPORTANT: TF E INFORMATION PROVIDED ON TEAS FORM IS INTENDED FOR GENERAL
<br /> RESPONSIBLE PARTY STATISTICAL PURPOSES ONLY AND IS NOT TO BE
<br /> CONSTRUED AS REPRESENTING THE
<br /> Enter name, telephone number, contact person, and address of the party OFFICIAL POSITION OF ANY GOVERNMENTAL AGENCY
<br /> responsible for the leak, The responsible party would normally be the tangy
<br /> owner. ,REMIEDIAL ACTION
<br /> indicate which action have been used to cleanup or remediate the Leak,
<br /> SITE LOCATION 'Descriptions of options 'follcw,
<br /> Enter—information regarding the'tank facility, At a minimum, you mast
<br /> provide the facility name and full. address, 22 Site �- install horizontal impermeable layer to reduce rainfall
<br />_F infiltration.
<br /> IMPLEMENTING ING AGENCIES Containment Barrier - install vertical dike to block horizontal- movement of
<br /> Enter- razes of the local, agency and Regi one:i Water Quality Control Boa-1"d cent az,inant,
<br /> involved, Excavate and Disose - remove contaminated soil and dispose in approved
<br /> site_
<br /> SUBSTANCES INVOLVED LVED Excavate and Treat - remove contaminated sail and treat (includes spreading
<br /> Enter the name and quantity last of the hazardous substance involved. Poor, or land farming),
<br /> A is provided for information on two substances if appropriate, f morc +axe.. Remove Free Product - remove floating Product, from. ,water table,
<br /> di
<br /> Psar _ and Treat Gro4andwater - generally employed to remove, dissolved
<br /> two substances leaked, fist the two of most concern for Meat"a.ap, _ f
<br /> ,ni t aminants.
<br /> DISC 4 ;}x,/ E fEMENa: Enhanced Blade rad stun - use o£ any ava^ able techna ogy to promote
<br /> Provide information regarding the discovery and abatement of the leak, bacterial decomposition of contaminants.
<br /> ?,ewlac . �upcly - provide alternative, caster supply to affected parties,
<br /> SC Pte` rat, a re atar n at No a instals water treatment devices at each dwelling or
<br /> s.dicate aurc s; of leak, Check box(es) indicating cause of leak, other place of use.
<br /> acuxExtract - use pumps or blowers to dram air thro:,gh soil
<br /> CASE TYTYPELaan int Soa'l - bore holes in soil to allow volatilization of contaminants,
<br /> Yn-yicate the case type category for this leak_ Check one box only, Case Nd Action ie:B lied - incident is minor, requiring no remedial, action,
<br /> type is based on the mostsensitive resource affected, For example, if
<br /> both sail and ground water have been affected, case type will be "CrouLd COMENTS - Use ;.his space to elaborate 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 "Ground Water" SIGNATURE - Sign the form in the space provided.
<br />{
<br /> designation does not amply that the affected water cannot be, sir is not,
<br /> used for drinking water, but only that water yells have not yet /:seen DISTRIBUTION
<br /> affected. It is understood that, case type may change upon further 17"the form is completed by the tarok owner or his agent, retain the last copy
<br /> investigationn. and forward the remaining copies intact to your Focal tank permitting agency
<br /> Sf for distribution.
<br /> CURRENT STATUS l., 0raginal - Local TankPermitting Agency
<br /> Indicate ;,lac category which best describes the current status of the case. 2, Stage Water Resources,Control Board, Division of Clean Water Programs,
<br /> Check one box ca ay. The response should be relative to the case type. For: Underground Storage Tank Program, P.O. Box 94421.2, Sacramento, CA 94244-
<br /> example, if case type is "Ground Water", than "Current Status" should refer 21,20
<br /> 'to the status of the ground water ineast9gation or cleanup, as opposed to 3, Regional. Water Quality Control Board
<br /> drat of soil. Descriptions of captions follow; 4,, Local Health Officer and County Board of Supervisors or their designee to
<br /> receive Proposition 65 noti"icatioxas.
<br /> No Action_ Taken - No action has :peer, taken by responsible party;beyond 5. Owner/responsible party,
<br /> re„i.:rt of leak.
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