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F '
<br />INSTRUCTION$ '
<br />EMERGENCY
<br />Indicate whethe:Pkmer%ncy respons,�'per nnekand :ft0*,.dol ent wer�vol d
<br />' at any time. If so, *'Hazard.. eri Indidentaud e fid
<br />withthaXtate 0 fice;,f Emergency tery es (�4�S) w R d, ; y
<br />Sacramento, CA832. Copies'of OE repof� form may l� obta' d af*y, $
<br />your local under rO. storage to pert ing agency In Fi.cate i� ietlier
<br />s the OES report has bene filed as tithe , ate this*epoj. *t 4
<br />&S 'r aw , r
<br />q LOCAL AGENCY ONkS(? •U y"� .y �
<br />To avoid duplicate no t ation tWuant0to Health and Sa cc Sec on 14
<br />2518€3.5, a government m ogee sh d n ar date the fornyin t "s bock.
<br />A signature her goes of mean thaathe leak 4s been determined, post a 90
<br />f significant threat to vman healtly, r s ety,4nly that nadificat on P M
<br />procedures havei en followed if r'� uiros.
<br />f -•.
<br />REPORTED BY
<br />F 'Enter your nametjtelephone ntunber, nd addrestl Indicate which party u
<br />represent and pie company tie , name.
<br />RESPONSIME PARTY �
<br />t «
<br />Enter n , telephone number, cont t person,nd address 6f the party y..
<br />responsible for the leak, The responsible pa would norppily be the tank
<br />owner. �
<br />SITE LOCA
<br />rfa litys At a minim$L, you must
<br />1990111t.i: 3t.t. it ti.t{. - •` •'� " ••'•tt' tit�iii.ii::az:::ii:i`'j, '
<br />IMPLEMENTING AGENCIES tom#
<br />Enter names of the loci l agency ariYl"Regional iter Quality*ontrol Board
<br />( involved, tq7
<br />P SUBSTANCES INVOLVED" j
<br />Enter the name and quahtityc, oat of the > azardous sub4tanci:involved. Loom
<br />t is progipr f�;' io two. Etbs aces' f app pria I£ morehan
<br />ccernr clnup.
<br />et
<br />. i
<br />DISCOVERY/ABATEMENT 4
<br />i
<br />' Provide information regardi the discovery a abat ment of the leak.
<br />6
<br />SOURCE/CAUSE
<br />Indicate source(s) of leak. Check box(e!) ina catin� cause of leak.
<br />€ CASE TYPE
<br />Indicate the case type catQry for this leak-) Cbecl one Bi)x only. Case
<br />type is based on the most sksitive resource aSfec':.ed. For example, -if
<br />both soil and ground water have been affectedcase type will be "Ground
<br />Water". Indicate "Drinking Water" only if onM,or more municipal or
<br />domestic water wells have actually been affecitol. A "Ground Water"
<br />designation does not imply that the affected tester cannot be:, or is not,
<br />used for drinking water, but only that water Wlls have not yet been
<br />affected. It is understood that case type may change upon further -s,�5,
<br />investigation. l",t
<br />CURRENT STATUS y
<br />Indicate the category which best descri4gs the current status of the case.
<br />Check one box only. The response shout ..be relativesi„o the case type..-UFor
<br />h example, if case type is "Ground Water";then "Curretit Status" should r4fer -4
<br />to the status -of the ground water inves i>ation or el@anup, as opposed 90 - I
<br />tt ,,- that of sol 1. Descriptions of options- flow:
<br />o�L
<br />No Action Taken - No action .has beer:aken by reonsible party be yFi id '
<br />i.nitia] re -part: of :Leak.. f. , y
<br />Leak me Bein Confir- Leak suspected at site, but has not been confirmed.
<br />Pref sinary Site sessment Workplan Submitted - workplan/proposo.._
<br />requested of/subm tsted by responsible party to determine whethea}##pund
<br />water has been, or will be, impacted as a result of the release— -,I-
<br />Pre liiiiinary
<br />IPreliminary Site Assessment Underway - implementation of workp}ran.
<br />Pollution Characterization - responsible party is in the process CC fully
<br />def Tong the extent of contamination in soil and ground water aM a4sessing
<br />impacts on surface and/or ground water.
<br />Remediation Plan - remediation plan submitted evaluating long t
<br />rem ation options. Proposal and implementation schedule for, ;opriate
<br />remeation options also submitted. ,ns '�
<br />Clea up Underway - implementatior%ef remediation plan.
<br />Post Cleanup Monitoring in Progre - periodic ground water or 0ktyr
<br />moni,jq ring at site, as necessary, to verify and/or evaluate efPebt&veness
<br />of remedial activities.1
<br />Case Closed - reg2onal Lrd and local agency in concurrence thA lk
<br />further work is necessary at the site.
<br />IMPORTANT: THE INFOATION PROVIDED ON THIS FORM IS AtTENDED FOR G�Ej;L
<br />STATISTICAL PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REPRESENTING T4
<br />OFFICIAL POSITION OF 4IY GOVERNMENTAL AGENCY
<br />REMEDIAL ACTION
<br />Indicate which action have been used to cleanup oVemediate the lei .i'
<br />Descriptio s of options follow:
<br />Cap e - install horizontal imptrmeable_Layer to reduce rainf#V1
<br />infi tration. ..••tt n atii::;::::i.::=:.:_: eg,
<br />Containment Barrier - install vertical dike to block horizontaL'jpojement of
<br />contaminant.
<br />Excavate and Dispose - remove contaminated soil and dispose in approved
<br />site.
<br />Excavate and Treat - remove contaminated soil and treat (inc7udq s_Vreading
<br />or land farming). r
<br />Remove Free Product - remove floating product from water table
<br />Pump and Treat Groundwater - generally employed to remove disso.ltjed
<br />contaminants. -
<br />Enhanced Biodegradation -- use of any available technology to promote
<br />bacterial decomposition of,kontaminants.
<br />Replace Supply - provide altTernative water supply to affected parties.
<br />Treatment 4 Hookun - install water treatment devices at each dwelS.,ng or
<br />other plac f use.
<br />Vacuum Extra t - use pumps or blowe:-s t� draw air through soil.
<br />Vent Soil - bore holes .in soil to all val.atilization of costemin s.
<br />No Action Required - incident is minor, requiring no remedial agtion.
<br />COMMENTS - Use this space to elaborate on any aspects of the incident. i
<br />SIGNATURE - Sign the form in the space provided.
<br />f
<br />DISTRIBUTION
<br />If the form is completed by the tank owner or his agent, retain the,as't copy
<br />and forward the remaining copies.intact to your local tank permittini agency
<br />for distribution.
<br />1. Original - Local Tank Permitting Agency a
<br />2. State Water Resources Contral Board, Division of Clean 'Water Programs,
<br />Underground Storage Tank Program, P.O. Box 944212, Sacramento, CA 94244-
<br />2120
<br />3. Regional Water Quality Control Board
<br />y. Local Health Officer and County Board of Supervisors or their designee to
<br />receive Proposition 65 notifications.
<br />5. Ower/responsible party.
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