COMPLIANCE INFO_1987-2001 - Laserfiche WebLink

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: NS R I i CN5 , EMERGENCY LeakBein& Conf ;red - Leak suspected at site, but has not beegi confirmed. Indicate whether emergency response personnel, and eTi=pment were involved Frelian Submitted -- workplan/proposal at any timd. If so, a hazardous Material Incident Report 5,ou"d be filed requested of/submitted by responsible party to determine whether ---ground with the,Siate Office of Emergency Services O:S) at 2800 Me,adow,,r.ew Road water has been, or will be, impacted as a result of the release. Sacramento, CA 951332. 'Copies of the OES report form may be obtained at Prelirirzary Sste:4ssessment Underway - implementation of workplan, your local underground storage tank permitting agency. Indicate whether Pollution Characterization - responsible party is in the process of fully the OES report has been filed as of the date of this re, ort, defining the extent of contamination in soil and ground water and asisssing impacts on ,surface and/or ground water. LOCAL AGENCY ONLY Remediation Plan - remediation plan submitted evaluating long term To avoid duplicate notification pursuant,to Health and Safety code Section- remediation options. Proposal and implementation schedule for appropriate 25781.5, a government employee slaou_d sign aznd date the form in * is block. remediation options also submitted,' A signature here does _not mean that the leak has been determined to pose a Cleanup Underway - implementation of romediataon plan. significant threat' to -human health or safety, only that notification Post CleanuMonitoring in Prngress - periodic ground mater or other proced,ureshave been followed if required. monitoring at site, as necessary., to verify and/or evaluate effectiveness of remedial activities. REPORTED BY Case Closed - regional board and iocai agency in concurrence that no ,. Enter your name telephone number, and address. Indicate which party you further work is necessary at the site, represent and provide company or agency name, " IMPORTANT: TETE INFORMATION PROVIDED,ON THIS FORM IS INTENDED FOR GENERAL RESIONSIBLE PARTY STATISTICAL PF ES ONLY D IS OT TO BE CONSTRUED AS REPRESENTING HE Enter name, telephone number, contact person, and address of the party OFFICIAL POSITION OF ANY GOVERNMENTAL AGENCY responsible for the leak. The responsible party would normally be the tares owner. REMEDIAL ACTION Indicate which action have been used to cleanup or remediate the leak. SITE LOCATION Descriptions of options follow: Enter information regarding the tank facility, t a minimum, you most provide the facility name and full address: Cap Site - instal" horizontal impermeable layer to reduce rainfall infiltration. IMF NTINC AGENCIES Containment Farrier -install veriicai, dike to block horizontal movement of Enter names of the local agency and Regional Water Quality control.. Board contaminant. involved. Excavate and Rjispose - remove contaminated soil and dispose in approved site. SUBSTANCES INVOLVED Excavate and Treat - remove contaminated soil and treat (includes spreading Enter the name and quantity lost of the hazardous substance involved. Room or land farming). is providedfor information on two substances if appropriate.: If more. than, Remove Free Product - remove floating product from Water table. two substances leaked, list the two of most concern for cleanup. Pump and Treat Gra, dwater - generally employed to remove dissolved _. GOntaminants. DISCCJVERY/ABATE NT Enhanced. Biodegradation use of any available technology to pscA oto Provide information regarding the discovery and abatement of the leak, bacterial decomposition of contaminants, Rexxlace Supply - provide alternative water supply to affected parties. SOURCEjCAUSE Indicate source(s) of leak. Check box(es) indicating cause of leak. Treatment at Hookup - install water treatment devices at each dwelling or other place of use, Vacuum Extract - use pumps or blowers to draw air through soil. CASE TYPE Vent Soil - bore holes in soil to allow volatilization of contaminants, Indicate the case type category for this leak. Check one box only. Case lio Action Required - incident is minor, requiring no remedial action,' type is based on the.most sensitive resource affected. For eirampl.e, if both soil and ground nater have been affected, case type will be "Ground COf+1ENT5 - Use this space to elaborate on any aspects of the incident. Water". Inditate "Drinking Water" only if one or more municipal or, domestic water wells have"actually been affected. A *:Ground Water" SIGNATURE - Sign the form in the space provided. designation -,,does not imply that the affected water cannot be, or is not, used for drirming water, naut^only that water wells have not yet been DISTRIBUTION affectedtt is understood that case type may change upon further If the form is completed by the tank owner or his agent, retain the last copy investigat,oxx. •`• and forward the remaining copies intact to your local tank permitting agency for distribution. 1. Original -Local Tank Permitting Agency Indicate tb§§ category which best describes the current status of the case. 2, State Water Resources Control Board, Division of Clean Water programs, Cheek one box only. The response should be relative to the case type. For Underground Storage 'Tank Program, P,0, Box 944212, Sacramento, CA-94244- exa-npl., if"pase type is "Ground rater" _then_ "Current Status" sSnould refer 2120 - to"the sta,z of the ground water investigation or cleanup. as opposed to 3. Regional relater Quality Control Board t'at of sofl Descriptions of options follow: 4. Local Health Officer and County Board of Supervisors or their designee to, f - T F receive Proposition .. notifications, NoAction Ta`,., - No action ? as been ,tarsen by responsible party beyond 5. Owner/responsible party. =it al-egr,rt of lean..