COMPLIANCE INFO_FILE 10 - Laserfiche WebLink

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IidSTRUC IONS EMERGENCY Leak Being Confirmed - Leak suspected at site, but has not been confirmed. Indicate whether emergency response personnel and eTaipment were involved Preliminary Site Assessment Workplan Submitted - workplan/proposal at any time. If so, a Hazardous Material Incident Report should be filed requested of/submitted by responsible party to determine whether ground wit'- the State Office of Emergency Services (OES) at 28GO Meadawview Road, water has been, or will be, impacted as a result of the release, Sacramento, CA 95832. Copies of the OES report form may be obtained at Preliminary Site Assessment Underway - implementation of workplan. your local underground storage tank permitting agency. Indicate whether 2ollution, Characterizatio-, - responsible party is in the process of fully the :DES report has been filed as of the date of this report. defining the extent of contamination in soil and ground water and assessing impacts on surface and/or ground water, LOCAL AGENCY ONLY Remediation -Plan - remediation plan submitted evaluating Long term To avoid duplicate notification pursuant to Health and Safety code Section remediation options. Proposal and implementation schedule for appropriate 25180.5, a government employee should sign and date the form in this block. remediation options also submitted. A signature here does not mean that the leak has been determined to pose a Cleanuv Underway - implementation of remediation plan. significant threat to htBran health or safety, only that notification Post Cleanup Monitoring in Progress - periodic ground water or other proced-ares have been followed if xe<ruired- monitoring at site, as necessary, to verify and/or evaluate effectiveness ofremedial activities. REPCPTED BY Case Closed - regional board and local agency in concurrence that no Enter your name, telephone number, and address- Indicate which party you further work is necessary at the site. represent and provide company or agency name. IMPORTANT: THE INFORMATION PROVIDED ON THIS FORM IS INTENDED FOR GENERAL RESPONSIBLE PARTY STATISTICAL PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REPRESENTING THE Enter name, telephone number, contact person, and address of the party OFFICIAL POSITION OF ANY GOVERNMENTAL AGENCY responsible for the leak. The responsible party would normally be the tank owner. REMEDIAL ACTION indicate which action have been used to cleanup or remediate the leak. SITE LOCATION Descriptions of options follow: Enter information regarding the tank facility. - a mirim um, you must provide the facility name and full address. Cap Site - install horizontal impermeable layer to reduce rainfall infiltration. IMPLEMENTING AGENCIES Containment Barrier install vertical dike to block horizontal movement of Enter names of the local agency and Regional Water Quality Control Board contaminant. involved. Excavate and Dispose remove contaminated soil and dispose in approved site, SUBSTANCES INVOLVED Excavate and Treat - remove contaminated soil and treat (includes spreading Enter the name and quantity lost of the hazard--us substance involved. Room or land farming). is provided for information on two substances if appropriate. if more than Remove Free Product remove floating product from water table. two substances leaked, List the two of most concern for cleanup. Pump and Treat Groundwater - generally employed to remove dissolved contaminants. DISCOVERY/ABATEMENT Enhanced Biodegradation - use of any available technology to promote Provide information regarding the discovery and abatement of the leak., bacterial decomposition of contaminants. Replace upul - provide alternative water supply to affected parties. SOHEgEICAUSE Treatment,-_aL_Hookup - install water treatment devices at each dwelling or • Indicate source(s) of leak. Check box(es) indicating cause of leak. other place of use. Vacuum Extract - use pumps or blowers to draw air through soil. CASE TYPE Vent Scall. - bore holes in soil to allow volatilization of contaminants. Indicate the case type category for this leak. (—Iack one box only. Case No Action Required - incident is minor, requiring no remedial action. type is based on the most sensitive resource affected- For example, if both soil and ground water have been affected, case type wall be "Ground COt-TIENTS Use this space to elaborate on any aspects of the incident. a Water". Indicate "Drinking Water" only if one or more =nicipal or domestic water wells have actually been affected. A "Ground Water" SIGNATURE Sign the form in the space provided. designation does not imply that the affected water cannot be, or is not, used for drinking water, but only that water wells have not yet been DISTRIBUTION affected. It is understood that case type may change upon further if the form is completed by the tank owner or his agent, retain the last copy investigation, and forward the remaining copies intact to your local tank permitting agency for distribution. CURRENT STATUS 1. original - Local Tank Permitting Agency Indicate the category which best describes the current status of the case, 2, State Water Resources Control Board, Division of C'ean Water Programs, Check one box only. The response should be relative to the case type. For Underground Storage Tank Program., F.O. Box 944212, Sacramento, CA 94244- ,3xample, if case type is "Ground Water", then "Curse Status" should refer 21201 t,o the status of the ground water investigat40, or cleanup. as opposed to 3. Regional Water Quality Control Board that of soil. Descriptions of options follow: 4. Local Health Officer and County Board of Supervisors or their designee to receive Proposition 6-1 notifications. No Action Taken - No action has been taken by responsible party beyond 5. Owner/responsible party. initial of leak.