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INSTRUCTIONS
<br />EMA14CY
<br />Indicate whether emergency response personnel and equipment were involved
<br />at Any time. If so, a Hazardous Material incident Report should be filed
<br />with the State Office of Emergency Services (OES),at 2800 Meadowview Road,
<br />Sacramento, CA 95832, Copies of the CES report form may be obtained at
<br />your local underground storage tank permitting agency. Indicate whether
<br />the OES report has been filed as of the date of this report.
<br />LOCAL AGENCY ONLY
<br />To avoid duplicate notification pursuant to Health and Safety code Section
<br />25180.5, a government employee should sign and date the form in this block.
<br />A signature here does not mean that the leak has been determined tc nose a
<br />significant threat to human health or safety, only that notification
<br />procedures have been followed if required.
<br />REPORTED BY
<br />Enter your name, telephone number, and address. Indicate which patty you
<br />epresent and provide company or agency name.
<br />RESPONSIBLE PARTY
<br />Enter name, telephone number, contact person, and address of the party
<br />responsible for the leak. The responsible party would normally be the tank
<br />owner.
<br />SITE LOCATION
<br />Enter information regarding the tank facility. , At, a minimum, you _TnIst
<br />provide the facility name and full address.
<br />IMPLET,I�G,�G,E,NgIES
<br />Enteram local agency and Regional Water Quality Control Board
<br />involved,
<br />SUBSTANCES INVOLVED
<br />Enter the name and quantity lost of the hazardous substance in-,,ol-jed. Room
<br />is provided for information on two substances if appropriate. if more than
<br />two substances leaked, list the two of most concern for cleanup.
<br />DISCOVER Y/ABATEtAZNT
<br />Provide information regarding the discovery and abateipent of the leak.
<br />SOURCE/CAUSE
<br />0
<br />n dicatesoqrcels) of leak. Check box(es) indicating cause of leak.
<br />ASE TYPE
<br />Indicate the case type category for this leak. Check one box only. Case
<br />type is based on the most sensitive resource affec.ed. For example, i - f
<br />both soil. and ground water have been affected, case type will be "Ground,
<br />Water". indicate "Drirding Water" only if one or more municipal or
<br />domestic water wells have actually been affected, A "Ground nater"
<br />designation does not -imply that the affected water cannot be, or is not,
<br />used for drinking water, but only that water wells have not yet been
<br />affected. It is understood that case type may change upon further
<br />investigation.
<br />CURRENT STATUS
<br />Indicate the category which best describes the- current status of th a case.
<br />Check one box only. The response should be relative to the case type. For
<br />example, if case type is "Ground Water". then "Current Status" shold
<br />refer
<br />to the status of the ground water .investigation or clearlup. as oppozer., to
<br />that. of so -i I , Descriptions of options fol.'ow:
<br />No Action Taker. No acti.,ori has been taken by responsible party
<br />init.4al resort. of =ak,
<br />Leak Being Confirmed - Leak suspected at site, but has not been confirmed.
<br />Preliminary Site Assessment Workplan Submitted - workplan/proposal
<br />requested of/submitted by responsible party to determine whether ground
<br />water has been, or will be, impacted as a result of the release,
<br />Preliminary Site Assessment Ulldenqay - implementation of workplan.
<br />Pollution Characterization - responsible party is in the process of fully
<br />defining the extent of contamination in Boil and ground water and assessing
<br />impacts on surface and/or ground water.
<br />Remediation Plan - remediation plan submitted evaluating long term
<br />remediation options. Proposal and Implementation schedule for appropriate
<br />remediation options also submitted.
<br />Cleanup Underway - implementation of remediation plan,
<br />Post Cleanup Monitoring, in Progress - periodic ground water or other
<br />monitoring at site, as necessary, to verify and/or evaluate effectiveness
<br />of remedial activities.
<br />'as.
<br />Case Closed - regional board and local agency in concurrence that no
<br />further work is rieclessary at the site.
<br />IMPORTANT: THE iNFORZMATION PROVIDED ON TRIS FORM IS INTENDED FOR GENERAL
<br />STATISTICAL PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REPRESENTING- THE
<br />HE
<br />OFFICIAL POSITION OF ANY GOVERNMENTAL AGENCY
<br />REMEDIAL ACTION
<br />Indicate which action have been used to cleanup or remediate the leak,
<br />Descriptions of
<br />options follow:
<br />Can Site - install horizontal impermeable layer to red -ice rainfall
<br />infiltration.
<br />Containment Barrier install vertical dike, to block horizontal movement- 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 (includes spreading
<br />or land farming).
<br />Remove Free Product remove floating product from water table.
<br />Fumn and Treat -Groundwater - generally employed to remove dissolved
<br />contaminants.
<br />Enhanced Biodegradation - use of any available technology to promote
<br />bacterial decomposition of contaminants,
<br />Replace Supply - provide alternative water supply to affected parties.
<br />Treatment at Bookup - install water treatment devices at each dwelling or
<br />other place of use.
<br />Vacuum Extract - use pumps or blowers to draw air through soil.
<br />Vent Sail - bore holes in soil to allow volatilization of contaminants,
<br />No Action Required - incident is minor, requiring no remedial action,
<br />COUNTS Use this space to elaborate on any aspects of the incident,
<br />,SIGNATURE Sign the form in the space provided.
<br />DTS-RIPUTION
<br />If the form is completed by the lank owner or his agent, retain tae last copy
<br />and forward the remaining copies intact to your local, tank permitting agency
<br />for distribution.
<br />1, Original - Local Tank Permitting Agency
<br />2, State Water Resources Control Board, Division of Clean Water Programs,
<br />Underground Storage Tank Program. P.O. Box 944212, Sacramento, CA 94244-
<br />2120
<br />3. Regional 'Nater Quality Control Board
<br />4, Local. Health Officer and County Board of Superviscrs or their designee to
<br />receive Proposition 65 notifications.
<br />5, party,
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