SITE INFORMATION AND CORRESPONDENCE_FILE 1

Home Browse Search

INSTRUCTIONS EMERGENCY - CURRENT STATUS n tT whether emergency response personnel and equipment were involved at - n ikota t e category which best describes the current status of the case. any tame time. If so,-a Hazardous Material Incident Report should be filed with _ Check one box only. The response should be relative to the case type. For -. - example, if case type is"Ground Water", then "Current Status" should refer to the State Office of Emergency Services (DES) at 2800 Meadowview Road, - _. Sacramento, CA 95832.. Copies of the DES report form may be obtained-at your the status of the ground Nater investigation or cleanup, as opposedto-that'of local undergrourVd'istorage tank permitting agency. Indicate whether the OES soil. report has been filed as of the date of this report. IMPORTANT: THE INFORMATION PROVIDED;YIN THIS FORM IS INTENDED FOR GENERAL - LOCAL AGENCY ONLY - STATISTICAL PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REPRESENTING THE o avo—iTduplicate 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 - this block. A signature here does not mean that the leak has been determined, REMEDIAL ACTION to pose a significant threat too uman health or safety, only that-notification n nate w x actions have been used to cleanup or remediate the leak. procedures have been followed if required. Descriptions of options follow:'ow: REPORTED BY Cap Site - install horizontal impermeable layer to reduce rainfall ntel er your name, telephone number, and-address. Indicate which.party you - tn' it tration. represent and provide company or agency name. _ Containment Barrier - install vertical dike to block horizontal movement of contaminant. - - RESPONSIBLE PARTY - -- Excavate and Dispose - remove contaminated soil and dispose in approved Enter name, telephone number, contact person, and address of the party -- - Etta. Excavate and Treat - remove contaminated soil and treat (includes responstible for the leak. The respogsible party would normally be the tank - spreadinglandor -farmi owner. - - - Remove Free Product - remove floating product from water SITE LOCATION -- - table. E—nterin�fo—rmation regarding the tank facility and surrounding area. At a Pump and Treat Groundwater - generally employed to remove dissolved minimum, you must provide the facility'name and full address. contaminants-,' _ Enhanced Bioftaradation - use of any available technology to promote " - - a�cten i ecompositi on of Contaminants. IMPLEMENTING AGENCIES Replace SuDDIy - provide alternative water supply to affected - Enter names local, agency and Regional-Water Quality:Control Board involved. - - - - -- parties. .. Treatment at Hood - install water treatment devices at each dwelling or SUBSTANCES INVOLVED otner place use. No Action Re uired - incident is minor, requiring no Enter the name and quantity lost of the hazardous substance involved. Room is _ 9 provided for information on two substances if. appropriate. If more than two '- retialaction. substances leaked, list the two of most concern for cleanujt. - COMMENTS - Use this space to elaborate on any aspects of the incident. DISCOVERY/ABATEMENT .SIN TUIFE - Sign 'the form in the space provided. rovide regarding the discovery and abatement of the..leak. ISTR UTION SOURCE/CAUSE - -' If the form is completed by the tank owner or his agent, retain the last copy ndic�rce(s) 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 boxesO 1. Original) indicating cause of leak. for rbution. igi - ". nal - Local Tank Permitting Agency CASE TYPE - - 2. State Water Resources Control Board, Division of Water Quality, Ind c�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 3. Regional Water Quality Control Board and ground water have been affected, case type will be "Ground Water".: 4. County Board of Supervisors or designee to receive Proposition 65 Indicate "Drinking Water" only if one or more municipal or domestic water - _ notifications. wells have actually been affected. A "Ground Water" designation does not - 5. Owner/responsible party. imply that the affected watercanno€-be, or is noti, -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.