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INSTRUCTIONS
<br />EMERGENCY ;,
<br />indicate whether amergeAcy response personnel and equipment, were involved
<br />at any time, If so, a Hazardous Material Incident Repdrt should be filed.
<br />witIl the Stitte Office of Emergency Services (OES) at 2800 MeadowviewRoad,
<br />Sac4
<br />amento, CA 95632. Copies of the OES report form may be obtained at
<br />you. local underground storage tar-,lt permitting agency. Indicate whether
<br />the GES report has been filed as o-£ the date o£,this reporE
<br />LOCAL AGENCY ONLY `
<br />To avoid duplicate. notification pursuant to F:eaith and f>afety code'
<br />Sectip r
<br />25180.5, a government employee shoald sign and date the `orris in t14s block.
<br />A signature here does n't mean that the leak ha -s been detertine: to pose a
<br />significant threat to human health or safety, only that notification
<br />procedures have been fol'l.owed if -.±squired.
<br />RTF.D BY . .
<br />er your name, teleplxone number,�.and adages. Indicate which pprty YOU,
<br />present and provide company or agency name. '
<br />RESPONSIBLE PARTY
<br />Enter name, telephone number, contact person, and addra'ss of the party -..
<br />responsible for the leak. The responsible party would„xao :mally be the tack
<br />owner. I-
<br />SITE LOCATION a
<br />Enter information regarding the tank facility, At a mini.nu.M, you must
<br />provide the facility name and full address.
<br />IMPLEMENTING AGENCIES
<br />Enter names 4f tl> local agency anT Reg.i.otial `tl#te-' Quality Control Board,:, -
<br />involved,
<br />SUBSTANCES INVOLVED y
<br />Enter the name,arfd quan-i,ity lost df the hazardp'us substance involved. Room
<br />is provided for information on two substances if apprgpxiate, If more than
<br />two substances leaked, -List the tWo of most concern for cleanup.
<br />DISCOVERY/ABAT£NT
<br />Provide information regarding the discovery., and abatement of the leak.
<br />JRCE CAUSE
<br />i icate source(s) of leak. Check box(es)-indicating cause of leak.
<br />"tea CASE TYPE A
<br />Indicate the case type category for this lee, Check one box only. Case
<br />type is based on the most sensitive resource affected, For,.example, if
<br />both soil and ground water have b2en affected, -base type will he "Ground
<br />Water". .indicate "Drinking Water";`only if one or more ti3unicipal or
<br />domestic water wells have actually been affected, A "Ground Water"
<br />designation does not imply that the affected water cannot be, or is not,
<br />used for drinking water, but oply that water wells have note yet been
<br />affected. It is understood tli�t case type::may change upon further
<br />.investigation.
<br />� L
<br />CURRENT STATUS_--
<br />.ndicate the category'which best d*scribes. Ti.. cur.rent"utat.us of the case.
<br />Check one box o'hl.y. The response�.should be relative to the. case type. For
<br />example, if case: type is "Ground :nater" t1.ea, Trent Status” should refer
<br />to the status of the ground wate.r74nvestigatIar or cleanlAp,,as opposed to
<br />thaf of sail. JLscripti.ens of opt_j,ons £olTCw,
<br />r No Action Taken - No action has been taken ty responsible party beyond -
<br />initial report, of leak.
<br />Leak Reins, COnfirmel - Leak.suspected at site, but has not been confirmed.
<br />P eliininary Site Assessment Workplan Submitted - workplan/propos*l
<br />requested of/submitted by responsible party to determine whether ground
<br />water has been, or will be, impacted as a result of the release.
<br />Pel minnary Site Assessment Underway - implementation of workplan.
<br />Pollution Characterization - responsible party is in tlae process of fully
<br />def.JnLng the extent of contamination ir. soil and ground water and assessing
<br />impacts on sr --face and/or ground water.
<br />Remediation Plan - remediation plan submitted evaluating long term
<br />remedzat.ion options. Proposal and implementation schedule for appropriate
<br />remediation options also submitted,
<br />Cleanup Underway - implementation of remediation plan,
<br />Post Cleanup Monitoring in Progress - periodic ground water or other,
<br />monitoring at s.ite,,as necessary, to verify and/or evaluate effectiveness
<br />Of remedial activities.
<br />Case Closed regional board and local agency in concurrence that no
<br />further work is necessary at the site.
<br />IMPORTANT: THE INFORMATION PROVIDED ON THIS FOM IS INTENDED FOR GENERAL
<br />STATISTICAL PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REPRESENTING THE
<br />OFFICIAL. POSITION OF ANY GOVERNMENTAL AGENCY
<br />REt[EDIAL ACTION
<br />Indicate which action have been used to cleanup or remediate the leak.
<br />Descriptions of options follow;
<br />Cip �i`e - install horizontal impermeable la's'er to reduce rainfall
<br />infiltration.
<br />Containment Barrier - install vertical dike to block horizontal movement,of
<br />contaminant
<br />Eecayat_ a d Di pose remove contaminated soil and dispose in approved
<br />site,
<br />- Excavate and Treat - remove contaminated soil and treat (includes spreadtM
<br />or land farming).
<br />Remove Free Product - remove floating product from water table.
<br />P, and Treat Groundwater - generally employed to remove dissolved `
<br />.ontami�tant,s .
<br />Enhanced Biodefradaticn - use of any available technology to promote
<br />bacterial decomposition of contaminants,
<br />Re laces - prpvide alternative water supply to affected parties,
<br />Treatment at Hookup - install water treatment devices at each dwej.:.ix;g or,
<br />other lace. of use.
<br />Y Vacuum Extract. - use pumps or blowers to draw air through soil, .
<br />Vent Soil - bare holes in soil to allow volatilization of contaminants.
<br />No Action Rpauired.,- .incident is minor, requiring no remedial action:
<br />COMMENTS - Use this space to elaborate on any aspects of the incident„
<br />SIGNATURE Sign the form in the space provided.
<br />DI. T'RIBUTION
<br />,. I£ the form is completed by the tank owner or his agent, retain the last-cap
<br />and forward the remaining copies intact to your local tank permitting agency .
<br />for distribution,
<br />1. Or iginall - Local Talik Permitting Agency
<br />2. State Water Resources Control Board, Division of Clean Water Programs,
<br />Underground Storage Tar -,k Program, P.O. Box 944212, Sacramento, CA 94244_
<br />2120
<br />3 Regional Water Quality Control Board
<br />4. Local health Officer and County Board of Supervisors or their designee to
<br />receive Px:.position 65 notifications.
<br />5. Groner/responsible party.
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