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INSTRUCTIONS
<br /> n, Ei`= GENCY beak Being Gaxsfirmed - Leak suspected at site, but has not been confirmed.
<br /> Indicate whether emergency response personnel and equipment were involved Preliminar .Site Assessment W-1-1— q,bmitted - workplan/proposal
<br /> at any tima.,. "If'Sol 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 O S report farm may be obtained'at preliminar> Site Assessment Under a implementation of workplan,
<br /> u
<br /> your local undergrond-storage tank permitting agency, indicate whether Pollution Characterization - responsible party is in the process of fully
<br /> the OZES report has bMen filed-as of the date; of this report. defining the extent cif contamination in sail and ground water and assessing
<br /> > impacts on surface and/or ground water,
<br /> LOCAL AGENCY ONLY Remediatiou Play) - remediation plan submitted evaluating long tern
<br /> To avoid duplicate notification pursuant to Health and Safety code Section remediation options. Proposal and .implementation schedule for appropriate
<br /> F
<br /> 2-1180,5, a governmentemployee should sign and date the form in this block, remediation options also submitted,
<br /> A signature here does -not :near: that the leak has been determined to posse a Cleanu 1.tnderwa implementation of remediation plan,
<br /> significant threat to lsurrsan.health a- safety, only that notification periodic groundwater or other
<br /> procedures have been followed if rewired, monitoring at site, as necessary, to verify and/or evaluate effectiveness
<br /> of remedial activities,
<br /> ItEP RTED BY Case Closed - regional board and local agency in concurrence that no
<br /> rater year name, tel6phone number, and address. Indicate which party;you further world is necessary at the site,
<br /> represent and provide company or agency ranee'.
<br /> 3PPQR�ANS; TgsE INfOR�1 Tlvil PROVIDED ON THIS EORm Zs INTENDED FOR wrFH L
<br /> Z,ESPONSIBLE PARTY > STATISTICAL Pi:,H'.k?L"I Fs ONLY AND IS NOT TO BE CONSTRUED AS REPRESENTING THE
<br /> Enter name, telephone number, contact person, and addres's of the par OFFICIAL POSITION pad ANY COVE IM NTfi Fv.2IdCY
<br /> responsible for the ..1eak, she responsible.,party would normally be the tank
<br /> s
<br /> owasez.
<br /> ERE
<br /> ACIGN
<br /> Indicate which action have been used to cllea mp or remediate the leak,
<br /> SITE LOCATION
<br /> Descriptions of options f .lov:
<br /> Enter information regarding the tank facility. At a minimum, you most
<br /> provide the facility nave and full 'acidness. Site, - install. horizontal impermeable layer to reduce rainfall
<br /> infiltration,
<br /> IMPL k1E=ING AGENCIES Containment Barrien install vertical dike to bock horizontal smvs,ne.nt of
<br /> Enter names.-of the .00� - a
<br /> �._a_ �l agency and Regional Water Quality csz2trol a,egara. contas-sxia;it.
<br /> ?
<br /> Excavate ininvalved. caira atecsoil, and dispose in approved
<br /> site.
<br /> ST STANCESPPVQL11 r1 IixeaYate card rr It - remove contaminated soil. and ,`seat (includes preading,
<br /> Eater the name and quantity lost of the hazardous substance inv l: ad. Room, or land farming),
<br /> is provided for information on two substances if appropriate. If nose than Remove Free Product - remove floating p.ro tuct from water table_,
<br /> two substances leaked, 'list the two of most concern for cleanup. generally employed to remove iiissoLv d
<br /> contwninants,
<br /> DZSCOV=RY/ABATE`;E T r, aced P :;c r, t.icr, mise of any av&.l.ael_e tcclhnology to pzo.,,ct}
<br /> Provide info--oration regarding the discovery arca abatement of the Iea:r, bucte_Jal de. ,lnposit:r, of contaminants,
<br /> pp Ian ,,.;tide alternative water supply to affected
<br /> gam. E Tr t nz m at�. l .i insts" water treatment devices at each dwelling or
<br /> )kleasour _'s; of leak. Check box(es) indicating cause O,f_ leak. n<<ae. p ,c:.e _h.�e.
<br /> Vac,llum Extract use pwraps or blowers to draw air through soil
<br /> CASE TYPE: - Vent i' - borf hales in soil to allow volat.ilication of cont a. ;.ant,s.
<br /> Z:aeicate the case type category for this lemon Check one box only. Cas o, Lolac; sneer mad � incident is minor, requiring no remedial actin,
<br /> type is based on the last sensitive resource affected, For example, if
<br /> bath sail and ground water have been affected, case type will be "Ground COVIMENTS Use this space to elaborate oxi 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 /> designation does not imply that the affected water cannot bk, or is not;
<br /> used for drinking water,.but only that water wells have not ye't been DISTRIBUTION
<br /> affected, It is uzzeierstaol thatcasetype may change upon farther I,f the form is completed by the tank owner or his agent, retain the last copy
<br /> investigation. and forward the remaining copies ntact to your localtank.permitting agency
<br /> for distribution,
<br /> CURRENT STATUS 1, Original_,- Local Tank Permitting Agency
<br /> Indicate the category which best describes the current status of the case. 2, State Water Resources Control Board, Division of Clean Water Programs,
<br /> Check one }sox only, The response should be' relat=ive to the case type. For Undergroind Storage Tank Program, P,O. Box 944252, Sacramento, CA 94244-
<br /> exa.nple, if case type is "Ground Water", tea "Current Status" should refer 2120
<br /> to the status of the ground grater investigation ,car cleanup, 'as opposed to 3. Regional`Water Quality Control Board
<br /> that of soil. Descriptions of options follow; 4. Local Health Off3c�r orad( County Board of Supervisors d their designee to
<br /> raceive.Iropusitia:a 65 ::ori icatiorgs.
<br /> No fiction Taken - Pio action las been taker: by' responsible'party beyond 5. Owner/retponsible party.
<br /> initial i Y_rt, a'° leak.
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