|
,7,T— a - . .... " . , . .. _ r • .-„� ,,., Nwp ,Y . .. } ry�- ., w x x.. ..mow ^'z
<br />j,777
<br />' 4 Q 1STRUCTIONS
<br />EMERGENCY Le ei totifir Leak suspected at site, but has, not been confirmed.
<br />IbdicatewhethelWme ncy respon per ttte` d e pme were invo d Pref in 9t seasment Work a "Submitted - workplan/prop
<br />at.any If so, Hazardous eri` I, ent rt ould fi' requested-of/�, ed by responsible party to determine wbeth and
<br />with the ate Q� ice f Emergency ery as, ) a �84)Q. adow ew vat has;Ysaen, or will be, in-Tacted as a result, -of the-releas
<br />Sacramento CA 4.&32. Copi-es of OE epo form may obta d a /- Pref ' d , ite Assessment Underway,implersentation of workpllY .
<br />your local undewou torage to per, tting agen Tn icate' )ether Pollution Characterization responsible party is in the process fully,
<br />the OES report has be filed as othe ata thi�repo defiliRng the extent of contamination in soil ,and graund water a sensing
<br />impacts on surface and/or gpqund water.
<br />LOCAL AGENCY ONS Reme ation Plan - remediation plan submitted evaluating long t
<br />To avoid duplicate n f .tion p uan a ith and Sa. y cc See n rein ation options. Proposal and implementation schedule for priate
<br />25180.5, a gave ant yee sh d s a date the € in s b k. rert�� .tion options also submitted,
<br />A signature heroes of mean tha the eak s been dete ined pa a CLealfup Underway - implementatio f remediation plan. V
<br />significant threat to vman healt r s ty my that n ficati ri PostCLeanup Monitoring in P o r periodic ground water or- h r
<br />procedures haveen followed if r lir monisorin& at site, as cessary, to verify and/or evaluate of eness
<br />s of remedial actio'tieJL
<br />s
<br />ORTED BY y Case CY_osad - renal and and local agency in concurrence, th
<br />Enter your name #kelephone number nd addres Indicate wk�ich party further.work_is necessary at -the site.
<br />111,
<br />represent and p ids company or ncy name. *3 i
<br />�i IMPORTANT THE INFOATION PROVIDED ON THIS FORM IS.IIfiTENDED FOR G
<br />ti SPON I PARTY STATISTICAL PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REPRESENTI T
<br />Enter na , telephone number, contit person, nd address the party OFFICIAL POSITION OF 4TY GOVERNMENTAL AGENCY
<br />responsible for the leak, The responsible pa �ij would no Lly be the tank
<br />owner. REMEDIAL ACTION 40 0
<br />Indicate which action have been used to cleanup or remediate the le
<br />SITE LOCATION Descript'a s of optiops follow:
<br />it At a mini you must
<br />;t Ca e - install horizontal impermeable layer to reduce rain
<br />1' r.r.r�.....�t. _-__--
<br />IMPL NTING AGENCIES Cotrtainment Barrier install vertical dike to block riuiizo� a of•
<br />R Enter nasties of the lob l agency ar#Regional ter Qualitiontrol Board contaminant. ..
<br />involved. Excavate aril Dispose - remove contaminated soil and dispose in a proved
<br />{ V - site.
<br />SUBSTANCE& INVOLV-2 *4+ Excavate and Treat - remove contaminated soil and treat (includ ending
<br />E Enter the name and qua}�tit ost of the lar us su tans involved. om or land farming).
<br />Esf app pri . If more' an Remove Free Product - remove floating product. -from water table.
<br />cern r c nup. Pump and Treat Groundwater - generally employed to remove disco
<br />contaminants.
<br />DISCOVERY /ABATEMENT Enhanced Biodegradation X.Otaminynts. f anavailable technology to promo
<br />Provide informatiV regard- the Ois, a abate ent of the leak, M bacterial decomposition a
<br />aRe lace Su - provide rnative water supply to affect,d p t s.
<br />SOURCE/CAUSE a Treatment Hooku - install water treatment devices at each d ng or
<br />Indicate source(s) of ak. Check box('06 in satin cause of leak. other plac f use.
<br />• Vacuum Ext a t - use pumps or blowers draw air through soil:
<br />B CASE .TYPE Vent Soil - bore holes in soil to alloyolatilization of cont n ts,
<br />Indicate the case typ at ry for this leak Cbe ne x only. .:Case No Action Rsauired - incident is minor, requiring no remedial a
<br />type is'based on the t ssitive resource a�[.fecte F example;kif
<br />both soil and ground er have been affecte case type 1 be "Ground COMMENTS - Use this space to elaborate on any `aspects of the incident.04
<br />Water Indicate "Dr ing Water" only if or�or more ipal or
<br />domestic water wells h e actually been affec44d.. A "'Gro&d Water" SIGNATURE - Sign the form in the space provided.
<br />designation.do.es not ,4 ly that,.tw affected ter cannot e, or is not,
<br />used for drinking,wa but only that water 011s have not yet been DISTRIBUTION
<br />affected^ lt.is uncle ood that case t e may change upon further If the form is completed by the tank owner or his agent, retain the copy
<br />investigation. iA 4 .. and forward the remaining copies intact to -your local tank permitti ency
<br />G for distribution. +y
<br />CURR61T 3T�TUS ~ d 1. Original - Local Tank .Permitting Agency y
<br />Indicate ,the cats o
<br />g ry, ich best descrilV the current statuslof the case. 2. State Water Resources Control Board", Division of Clean Water Prows,
<br />Check onq box only. The response shoul4ke re
<br />!'tlative4jo the case type. 4Wgr Underground Storage Tank Program P.O. Box 944212, Sacramento, CA 44-
<br />+ example, if case type is "Ground Water"hen "Curre+b Status" should Mer 2120
<br />' •
<br />to the status of the ground wa�er investlglation or c�anup, as ..opposed � 3: Regional`Watet i2ua-lit�ic_Contrpl Board
<br />f that o£ soil..'beseriptiona of options) low. '*"':•.`� `-'` + 4. Local Health A€ficer,and Coutty Board of Supervisors or their designee to
<br />444 : receive Proposition 65 notifications.
<br />No Action Taken - No action has beet,aken by reronsible party be4d &4' 5. Owner/responsible party<
<br />initial report of leak.
<br />E
<br />.e
<br />,� ;$ ..... __ '- :•.. �.. *�' .: � ... € ��_. .r..�.-.�.�__-'-_-�<...-_ten..___ _.. � i._�,a. •a.
<br />_ . ....u........,:...,..<..� �:� .�
<br />
|