COMPLIANCE INFO_1987-2002 - Laserfiche WebLink

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x a INSTRUCTIONS , CURRENT STATUS EMERGENCY ndicate whether emergency response personnel and equipment were involved at , n cafe t e category which best describes the current status of the case. Check box The response should be relative to the case type. For any time. if sg-, a Hazardous Material Incident Report should be filed with a one only. ,, example, if case type is,,:tround Water", then "Current Status" should refer to the State Office of Emergency Services (oES),at 2$00 Mea2lowview;Road, `maybe the status of the ground water investigation or cleanup, as opposed to that of Sacramento, CA 95832., --Copies of the DES report form obtained at your ^ soil. local undergro n'd storage tank permitting agency.— Indicate whether the DES report has been filed as of the date -of thi3 repoet. -IMPORTANT: THE INFORMATION PROVIDED ON THIS FORM IS INTENDED FOR GENERAL F SThT-ISTICAL PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REPRESENTINq THE LOCAL AGENCY ONLY To avoid dup irate notification pursuant to :Health and Safety Code Section OFFICIAL POSITION OF ANY GOVERNMENTAL AGENCY 25180.7, a designated government employee should sign and date -the form in ; REMEDIAL ACTION this block. A signature here does not mean that the leak has been determined: In irate which actions have been,.used to cleanup or remediate the leak. to pose a significant threat to umarr health or safety, only that notification Descriptions of options follow: --- procedures have been followed if required. Caa Si'L - install horizontal impermeable layer to reduce rainfAll REPORTED BY infiltration. 'Enter your name, telephone number, and address. Indicate which party you Containment Barrier - install vertical dike to block horizontal movement represent and provide company or agency name. of contaminant, Excavate and Dispose - remove contaminated soil and dispose in ,approved RESPONSIBLE PARTY "nter name, to ephone number, contaci'person, and address of the party " Excavate and Treat - remove contaminated soil and treat (includes " responsible for the leak. The responsible party would normally be the tank .. spreadingor land farming). owner. Remove Free Product - remove floating product from water t SITE LOCATION nter 5 ormation regarding the tank facility and surrounding area. Ata table. Pump and Treat Groundwater -generally employed to remove dissolved "-, minimum, you must provide the facility name end full address. contaminants. Enhanced Biodegradation - use of any available technology to promote ariaT decomposition of contaminants. - IMPLEMENTING AGENCIES , Enter names o the local agency and Regional -Water: Quality Control Board _ _. Replace Supply- provide alternative water supply to affected - ,. w - parties. i nvolved. t Treatment at Hookup - install water treatment devices at each dwelling or SUBSTANCES INVOLVED Enter the name"an last of haiardous ubstance invot�ted. Room ig ot�ier place of use. No Action Re aired -incident is minor, requiring no ' quantity .the provided for'Jhformation on talo subitances_if appropriate. If more than two -' remeaia�acNN substances leaked, list the two of most concern for cleanup. " - COMMENTS - Use this space to elaborate on any aspects of the incident. DISCOVERY/ABATEMENT SQA URE - Sign the form in the space provided. rovideinformation regarding the discovery and abatement of the leak. DI BU ION If the form is completed by the tank owner or his agent, retain the last copy SOURCE/CAUSE ndicate sources) 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 boxigs) indicating cause of leak. for distribution. 1. Original - Local Tank Permitting Agency 2. State Water Resources Control Board, Division of Water Quality, CASE TYPE In irate 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 "Ground 3. Regional Water Quality Control Board 4. Count Board of Supervisors or designee to receive Pro osition~65 County p 9 P and ground water have ;been affected; case type pfi91 be Water". notifications: Indicate "Drinking Wate(" only. if one or more municipal or domestic water =: `"" "Ground party. 5. Owner/,responsible art wells have actually been affected. A Water"' designatiop'does not imply that the affected water -cannot be, of -Js 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.-•.