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FIM�NCY INSTRUCTIONS
<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 Of -'ice of Emergency Services (OES) at 2800 Meadowview Road,
<br />Sacramento, CA 95832. Copies of the GES 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 dries not mean that the leak has been determined to pose 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 party 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 must
<br />provide the facility name and full address,
<br />IMPLEMENTING AGENCIES
<br />Enter names of the local agency and Regional Wate-- Quality Control Board
<br />involved.
<br />SUBSTANCES INVOLVED
<br />Enter the name and quantity lost of the hazardous substance involved. Room
<br />is provided for information on two substances if approprd ate. If more than
<br />two substances leaked, list the two of most concern for cleanup.
<br />DISCOVERY/ABATEMENT
<br />Provide information regarding the discovery and abatemen't of the I'leak.
<br />SOURCE/CAI�
<br />ndicate source(s) of leak. Check box(es) indicating.cause of leak.
<br />ASE TYPE
<br />-Indicate the case type category for this leak. Check ore box only. Case
<br />type is based on the most sensitive resource affec.ed, For example, if
<br />both soil and ground water have been affected, case type will be "Ground
<br />Water". Indicate "Drinking Water" only if one or more municipal or
<br />domestic water wells have actually been affected- ' A "Ground Water"
<br />designation does rot 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.u.nderstood that case type may change -upon further
<br />investigation.
<br />CURRENT STATUS I
<br />Indicate the category which best describes the current status of the case.
<br />Check one box only. The response should be relative to the case type. For
<br />example, if case type is "Ground Water". t.han "Current Status" should refer
<br />to the status of the ground water investigation or cirankip, as oppored to
<br />that of soil. Descriptions of options follow:
<br />No Action Taken - No action has bean taken by res,
<br />ponsible pantry beNcMd
<br />initial report: of leak.
<br />Leak Being Confirmed - Leak suspected at site; but has not been confirmed.
<br />Preliminary Site As=essment 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 Uriderwav - implementation of workplan.
<br />Pollution Characterization - responsible Party is in tize process of fully
<br />defining the extent of contamination in soil :and ground water and assessing
<br />impacts on surface and/o.i.- ground water.,
<br />Remedi.21_io.n. Plan - remediation plan silbmitl,-ad evaluating long term
<br />remediation options. Proposal and schedule for appropriate
<br />remediation options also submitted.
<br />Cleanup Underway - implementation of remediation plan.
<br />Post ClearluE Monitor"nZ in Progress periodic ground water or other
<br />monitoring at site, as necessary, to verify and/or evaluate effectiveness
<br />of remedial. activities,
<br />Case Closed - regional board and local agency in concurrence that no
<br />further work is necessary at the site.
<br />IMPORTANT: THE INFORMATION PROVIDED ON THIS FORM IS INTENDED FOR GENERAL
<br />STATISTICAL PURPOSES ONLY AND IS NOT TO BF CONSTRUED AS REPRESENTING THE
<br />OFFICIAL POSITION OF AJ4Y 'GOVERNMENTAIT AGENCY
<br />REMEDIAL ACTION
<br />Indicate which action have been used to cleanup or remediate the leak.
<br />Descriptions of options follow:
<br />Cap Site - install horizontal impermeable layer to reduce rainfall
<br />infiltration.
<br />Containment Barrier install vertical dike to block horizontal movement of
<br />contam4nant.
<br />Excavate and Disoose, remove cant aminated soil and dispose in approved
<br />site.
<br />Encavate and Treat - remove contaminated soil. and treat (includes spreading
<br />or land farming).
<br />Remove Free Product - remove floating product from water table.
<br />Pumn 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 w;;'ter
<br />ter supply to affected parties.
<br />Treatment at "ook-Lao - install water treatment devices at each dwelling or
<br />otQiar place of use.
<br />Vacuum Extract - use pumps or blowers to draw air through soil.
<br />Vent, Soil - bore holes in soil to allow volatilization of contaminants,
<br />No Action Required - incident is minor, requiring no remedial act' -on,
<br />Cr,)!,.'-TFNTS - Use this Space to elaborate on any aspects of the incident
<br />SIGNATURE - Sign the form in the space provided,
<br />DIS7 IBUTICN
<br />if the form is completed by the tank owner or his agent, retain the last copy
<br />, a,n a forward the remaining copies intact to Your local tank permitting agency
<br />for d s t r , t
<br />;, lbuion,
<br />1, Orig.-nal - Local Tank Permitting Agency
<br />2. S' ate Water Resources Control Board, Division of Clean Water Programs,
<br />Underground Storage Tank Program. P.O. Eox 944212, Sacramento, CA 947,44 -
<br />al .nater Quality Control Board
<br />4, Locall Health Offi;,er and County Board of or rjej*,,,: to
<br />ret,,eive Froposition 65 notifications.
<br />party.
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