|
iNSTRUCTICS:S
<br /> 2' EMERGENCY Leak Beim Corafirned Leak suspected at site, but has not been confirmed.
<br /> Indicate whether emergency response-porso sol and e<uipment, were involved Preliminary Site Assessment Work laa Submitted - workplan/proposal
<br /> at any time,. If stn-, a Hazardous Material Incident Report-'should be filed requested of/submitted by responsible party to determine whether ground
<br /> ."
<br /> with the State Office of Emergency Services (CES); at 2804 tieadowview Road, water has been, or will be, i cacted as a result of the release,
<br /> Sacramento, CA 9533 , Copies or the- C7 repot ,o,1-, :nay be obtained a Prel.ian n1- Ste.As essay -r ISndersa - nple entetion of workplan
<br /> i .
<br /> your local underground storage tank permitting agency, - indicate whether , Pollution Characterization, - resporsible party is in the prowess of fully
<br /> the OES report has hien filed as of the date,of ,this report, defining the extent of contamination i.n soil arc.'- ground water and assessing
<br /> J impacts-on surface and/or ground water,
<br /> LOCAL, AGENCY ONLY E{er ediatiora plan - remediation plan submitted evaluating long term
<br /> To avoid duplicate notification pursuant to health and Safety code Section:- remediation options. Proposal and implementation schedule for apftopriate
<br /> 2518 .5, a government employee should sign and date the form in thia-block.` remediatjon options also submitted,
<br /> A signature here does not mean that the leak 11as been determined to-pose a Cleaners Under—, - implementation of .remediation pian,
<br /> signs cant threat to nzman health or safety, only that"notiiicaticn in in r`ess - periodic ground water or ether,.
<br /> procedures have been followed if required monitoring at site, as necessary, to verify and/or evaluate effectiveness-
<br /> - -- "_ of remedial activities,
<br /> PORTED BY � ' Case Closed -� reg oral board and ocol sgeney it concurrence this r 4
<br /> rater your name telephafle number, and address. Indicate which party you further,'?aork is necessary at the site,
<br /> epresent and provide company or agency nose.
<br /> IMPORTANT, THE INFORMATION PE OVIDED ON THIS FOR!; `IS INTENDED F GENERAL
<br /> RESPONSIBLE PARTY STATISTICAL PURPOSES ONLY AND IS NOT TO BE CONISTRUED AS REPRESENTING THE
<br /> Enter name, telephone numbar, contact person" and address of the party OFFICIAL POS?TIO14 OF ANY GOVERIC :R AL AGENCY
<br /> responsible for the Leak., The regGnsible party would normally be the tank
<br /> owner. RE' ;DIAL ACTION
<br /> indicate which action have been used to cle,nip or remediate the leak,
<br /> SITE LOCATION _ Descriptions of options follow:
<br /> Enter information regarding the tank facility. At a minimum, you rxasr
<br /> prnvade the facility none=and lull adds >s. Gap Site - instal], horizontal n =a. iumntiraeable ;Layer to reduce rainfall
<br /> infiltration, 4
<br /> IMPLEtI NTI G AGENCIES Containment Barrier install vexfi cal d �e Mss to h k
<br /> _ ,: __o rrora.r,.a, movement-of
<br /> Enter names of the local agency and Regional Wa e-Z Quality Control Board contaminant,
<br /> involved. Excavate and :i s one - rmnove contaminated sell. and dispClse in approved
<br /> w,
<br /> :site.
<br /> SUBS htv 5 TN'GL tI Excavate and Treat _eleaae contao.s.aated sell, and treat, (inc'GFees spreading
<br /> y Enter the name and quantity lost of the hazardous .,t r lama farming).=��:aa�axsce snvf,rvrd. nom o�Room
<br /> is provided for information on two substances if as opiae, If core tbRemoFree a remove flLoating product frcnwater table,
<br /> two substances leaked, list the two of most concern far cleanup. f2cl, n no T: e t ils z a generally ,,m loyed to remove :a,soi',ved
<br /> DISCOVERY/ABATEMENT ni anc:ecI Bia,BY,pc:
<br /> tL2 - use of oily a <r;,_<:rie technology t,= pxc rte
<br /> Provide information regarding the discovery and abatement of the ;.eek. bacterial decomposition of contam4nants,
<br /> Rear._ r � pa:° i e aalt,ernata re caster sopply to alfe tWd -,t-' ,
<br /> SC 4t Ft FUSE 'moat;n t. Hoo � � -a stall water treatment devices W eac:E ,gelling or
<br /> �I" ica e source(se. of Leak, Check box(es), -indicating cause orleak. o -er place of use,
<br /> Vacuum Extra " use pumps or blowers to draw air through sail.
<br /> CASE rYFE pant Soil - bore 'soles in .soil to allow volatilization of coni a dzdants.
<br /> a
<br /> Indicate the case ,type category for this leak, Check one box only, Case No Aeti.o, TtxM a cti - :incident is minor, re airing no remedial action,
<br /> type is based on the most sensitive resource affected. For example, if
<br /> both soil and ground water have been_affected., case type will, be `Ground CCI'3`FN S Use this space to elaborate on any aspects of the incident,
<br /> Water". Indicate, "Drinking Plater" only if one or more municipal or
<br /> domestic water wells have actually been affected, A "Ground Water" SIGNATURE - Sign the form in the space provided,
<br /> designation does'not imply the'; the affected water cannot he, or is not,
<br /> la � ,s
<br /> used fdr
<br /> or inkisng',water, but only that, water wells have not yet been DISTRIBUTION
<br /> a€fected. It is understood that" casetype-6ay change upon further If the form is completed by the tank owner or„xis agent, retain, the last':eopy
<br /> investigation. - and forward the remaining copies intact to your local tank permitting,agency-
<br /> for distribution,
<br /> CURRENT STATUS ., 1, Origi
<br />
|