COMPLIANCE INFO_1986-1996 - Laserfiche WebLink

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INSTRUCTIONS EMERGENCY CURRENT STATUS n icate whether emergency response personnel and equipment were involved at TnWcate t e category which best describes the current status of the case. =- any time. If so, a Hazardous Material Incident Report should be filed with Che;k one box only. The response should be relative to the case type. For "Current ' the State Office of Emergency Services (OES) at 2800 Meadowview Road, - example, if case type is "Ground Water", then „Status" should refer to Sacramento, CA 55832. :Copies of the DES report form may be obtained :at your the status of the ground water investigation or cleanup, as opposed to that of local underground storage tank permitting agency. Indicate whether the DES soil. report has been filed as of the date of this report. - IMPORTANT: THE INFORMATION PROVIDED ON THIS FORM IS INTENDED FOR GENERAL LOCAL AGENCY ONLY STATISTICAL PURPOSES ONLY AND, IS NOT TO BE CONSTRUED AS REPRESENTING THE ' To avoid duplicate notification pursuant to Health and Safety Code Section OFFICIAL POSITION OF ANY GOVERNMENTAL AGENCY 25180.7, a designa-ted government employee should sign and date the form in this block. A signature here does not mean that the leak has-been determined REMEDIAL ACTION to pose.a significant threat to—iuman health or safety, only that notification, Indicate which actions have been used to cleanup or remediate the leak. procedures have been followed if required. Descriptions of options follow:' REPORTED BY _Cap Site install horizontal impermeable layer to reduce rainfall Enteryour name, telephone number, and address. Indicate which party you inkration. represent and provide company or agency name. - _ Containment Barrier - install vertical dike to block horizontal movement - of contaminant. RESPONSI$LE PARTY Excavate and Dispose - remove contaminated soil and dispose in approved ' Enter name, telephone number, contact person, and address of the party responsible for the leak. The responsible party would normally be the tank site. Excavate and Treat = remove contaminated soil and treat (includes owner. sprea ing or an farming)• Remove Free Product - remove floating product from water SITE LOCATION nter in ormation regarding the tank facility and surrounding area. At a table. Pump and Treat Groundwater - generally employed to remove dissolved -" minimum, you must provide the facility name and full address. contaminants. Enhanced Biodegradation ='use of any available technology „to promote '~ IMPLEMENTING AGENCIES bacterra ecompos tion of contaminants. nter.nines o the local agency and Regional Water Quality Control Board Replace Supply - provide alternative water supply to affected ' involved. parties. Treatment at H_o_okup - install water treatment devices at each dwelling or SUBSTANCES INVOLVED of er p ace o use. Enter the name an quantity lost .of the hazardous substance involved. Room is No Action Required - incident is minor, requiring no provided for information on two'substances if appropriate. If more than two re— medial action. substances "leaked, list the two of most concern for cleanup. COMMENTS - Use this space to elaborate on any aspects of the incident. DISCOVERY/ABATEMENT Ib1 A TURE --Sign the form in the space provided. rovide information regarding the discovery and abatement of the leak. OSfFYBUTION SOURCE/CAUSE If the form is completed by the tank owner or his agent, retain the last copy ndic3 ate source(s) of leak. Provide details on tank; age; capacity and and forward the remaining copies in tact to your local tank permitting agency material if known. Check box(es) indicating cause of leak. for distribution. :, 1. Original - Local Tank Permitting Agency ; CASE TYPE 2. State Water Resources Control Board, Division of Water Quality, indicate the case type category for this leak. Check one box only. Case type. Underground Tank Program, P. 0. Box 100, Sacramento, CA 95801 is based on the most sensitive resource affected. for example, if both soil 3. Regional Water Quality Control Board and ground water have been affected, case type will be "Ground Water" 4. County Board of Supervisors or designee to receive Proposition 65 Indicate "Drinking Water" only; if one .or more municipal or domestic water notifications. well's have actually been affected. A "Ground Water" designation does not 5. Owner/responsible party. " 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. 4