COMPLIANCE INFO_1996-2004 - Laserfiche WebLink

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INSTRUCTIONS EMERGENCY Indicate whether emergency response personnel and 8quipment were involved at any time. If so, a Hazardous Material Incidexit Report should be filed with the State Office ofEmergencyServices (OES)_at 2800 Meadowview"jzoad, Sacramento, CA 45832. C6pies of the OES report dorm may obtained at your local underground storage tank"permitting agency, indicate whether the OES report has hien,filed as of the date, of this report. LOCAL AGENCY ONLY' To avoid duplicatenotification pursl4ant to Health and Safety code Ssction 25280.5, a government employee should sign aiid date the;form in this Klock. A signature here does not'mean that the leak has been determined to pose a significant threat to human health or -safety, only that notification procedures have been followed if required. REPORTED BY " Enter your name, telephone number, and address. Indicate which party you represent and provide company or agency name. RESPONSIBLE PARTY Enter name, telephone number, contact person, and address of the party responsible for the leak. The responsible party would normally be the tank owner. - SITE LOCATMN Enter infAmation regarding the tank facility. At a minimum, you must provide the facility name and full address. IMPLEMENTING AGENCIES Enter names of -the local ,pgency.and Regional Water Quality Control Board involved. SUBSTANCES INVOLVED Enter the name and quantity lost of the hazardous substance involved. Room is provided for information on two substances if appropriate. If more than two substances leaked, list the two of most concern for cleanup. DISCOVERY/ABATEMENT Provide information regarding the.discovery and abatement of the leak. SOURCE/CAUSE Indicate source(s) of leak. Check bof(es) indicating cause of leak. CASE TYPE , Indicate the case type category for this leak. Check one box only. Case type is based on the most sensitive resource affected. For example, if both soil and ground water havd been affected, case type will be "Ground Water". Indicate "Drinking Water" only if one or more municipal or domestic water wells have actually been affected. A "Ground Water" 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 affected. It is understood that case type may change upon further ,investigation, CURRENT STATUS Indicate the category which best describes the current status of the case. Check one box only. The response should be relative to the cage type. For example, if case type is "Ground Water", then "Current Status'l`should refer. to the status of the ground water investigation or cleanup, as opposed to that of soil. Descriptions of options follow: No Action Taken - No actioxy has been taken by responsible party beyond initial report of leak, Leak Being Confirmed - Leak suspected at site, but has not been confirmed. Preliminary Site Assessment Workplan Submitted - workplan/proposal requested of/submitted by responsible party to determine whether ground water has been, or will be, impacted as a result of the release. Preliminary Site Assessment Underway - implementation of workplan. Poliut n Characterization - responsible party is in the process of fully defining the extent of contamination in soil and ground water and assessing impacts on surface and/or ground water. Remediation Plan - remediation plan submitted evaluating long term remediation options. Proposal and implementation schedule for appi6priate remediation options also submitted. Cleanup Undarway - implementation. of remediation plan. Post Cleanup on.itaring in.Pro ress - periodic ground water or other monitoring at site, as.necessary, to verify and/or evaluate effectiveness . ofremedial activities. _ Case Closed - regional board and local agency in concurrence that nes further :cork is necessary at the site, IMPORTANT: THE INFORMATION PROVIDED ON THIS FORM IS INTENDED FOR GENERAL STATISTICAL PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REPRESENTING THE OFFICIAL POSITION OF ANY GOVERNMENTAL AGENCY REriDIAL ACTION Indicate which action have been used to cleanup or remediate the leak. Descriptions.of options follow: Cap Sife - install hz;rizontal impermeable layer to reduce rainfall infiltration. Containment Barrier - install vertical dike to block horizontal movement of contaminant. , Excavate and Dish ose - remove contaminated soil and dispose in approved site. Excavate and Treat - remove contaminated soil and treat (includes spreading or land farming), Remove Free Product - remove floating product from water table. Pump and Treat Groundwater - generally employed to remove dissolved contaminants. Enhanced Biod�ion - use of any available technology to promote bacterial. decomposition of contaminants. Replace Supply - provide alternative water supply to affected parties. Treatment at Hookup - install water treatment devices at each dwelling or other place pf use. Vacuum Extract - use pumps or blowers to draw air through soil. Vent Soil -- bore holes in soil to allow volatilization of contaminants. No Action Required - incident is minor, requiring no remedial action. CCA44ENTS - Use this space to elaborate on any aspects of the incident.. SIGNATURE - Sign the form in the space provided. DISTRIBUTION If the form is completed by the tank owner or his agent, retain the latt"6opy and forward the remaining copies intact to your local tank permitting agency for distribution. - Original - Local Tank Permitting Agency 2. State Water Resources Control Board, Division of Clean Water Programs, Underground Storage Tank Program, P.O. Box 94422.2, Sacramento, CA 94244- 21-20 3, Regional Water Quality Control Board 4. Local Health Officer and County Board of Supervisors or their designee to receive Proposition 55 notifications. 5. Owner/responsible party,