COMPLIANCE INFO_1986-1996 - Laserfiche WebLink

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INSTRUCTIONS EMERGENCY Indicate whether emergency response personnel and equipment were involved at any time. If so, a Hazardous Material Incident Report should be filed with the State Office of Emergency Services (OES) at 2800 Meadowview Road, Sacramento, CA 95832. Copies of the OES report form may be obtained at your local underground storage tank permitting agency. Indicate whether the OES report has been filed as of the date of this report. LOCAL AGENCY ONLY To avoid 'duplicate notification pursuant to Health and Safety code lection 25180.7, a designated government employe should sign and date the form in this block. 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 LOCATION Enter information regarding the tank facility. At a minimum, you must provide the facility name and full address. IMPLEMENTING AGENCIES Enter names of the local agency and Regional Water Quality Control Board Involved. SUBSTANCES LE91 O Enter the name and quantity lust of the hazardous substance involved. Roan is provided for information on two substances if appropriate. If more than two substances leaked, list the two of most concern for cleanup. Provide Information regarding the discovery and abatement of the leak. 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. Pollution 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 appropriate remediation options also submitted. Cleanup Underway - implementation of remediation plan. i Post Cleanup Monitoring in Progress - periodic ground water'or,other monitoring at site, as necessary, to verify anti/or evaluate effectiveness of remedial activities Case Closed - regional board and local agency in concurrence that no further work is necessary at the site. AML 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 REMEDIAL ACTION Indicate which action have been used to cleanup or remediate the leak. Descriptions of options follow: Cap Site - install horizontal impermeable layer to reduce rainfall infiltration. ContaiDeent Barrier - install vertical dike to block horizontal movement of contaminant. Excavate and Dispose - 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. Pa., Pump and Treat Groundwater - generally employed to remove dissolved contaminants. Enhanced Biodegradation - use of any available technology to promote bacterial decomposition of contaminants. Reol'kce Sutiply - provide alternative water supply to affected parties. SOURCE/CAUSE Treatdment at Hookup - install water treatment devices at each dwelling or Indicate source(s) of leak. Check box(es) indicating cause of leak. other place of use. I Vacuum Extract - use pumps or blowers to draw air through soil. CASE TYPE � Indicate the case type category for this leak. Check one box only. Case4 type is based on the most sensitive resource affected. For example, if ' both soil and ground water have been affected, case type will be "Grounld 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 case type. For example, if case type is "Ground Water", then "Current Status" 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 action has been taken by responsible party beyond initial report of leak. Leak Being Confirmed - Leak suspected at site, but has not been confirmed. Vent Soil - bore holes in soil to allow volatilization of contaminants. No Action Required - incident is minor, requiring no remedial action. - 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 last copy and forward the remaining copies intact to your local tank permitting agency for distribution. 1. Original - Local Tank Permitting Agency 2. State Water Resources Control Board, Division of Loans and Grants, Underground Storage Tank Program, P.O. Box 944212, Sacramento, CA 94244- 2120 3. Regional Water Quality Control Board 4. County Board of Supervisors or designee to receive Proposition 65 notifications. 5. Owner/responsible party. El