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3 �Z INSTRUCTIONS
<br /> EMERGENCY � �� Leak Being Confirmed - Leak suspected at site, but has not been ccrkfirmed
<br /> Indicate whether erggicy response pers3iinel and equipment were involved,". ��, Preliminary Site kssessment Workplan Submitted - workplan/propopa]+.i"rc
<br /> at any tiale. If so, a A,a2ardous l3:ter1a1t ncident Report should be filed jf j. � `. requested of/submitcted by responsible party to determine whethe`r¢g Dun � <
<br /> with,the state Lff.ice dt (mer enc Services {OES} at 18 0 !1eadowview Road` ( J water has been, or shill be, impacted as a result of the releaae.
<br /> Sacramner,c� CA 95332. Copies the OES report farm ma be,abtained at:'�. �' Preliminary Site Assessment Underway - implementation of workplaK'f
<br /> youl!local underground storage tank permitting agency., %Indicate whether Pollution Characterization - responsible party is in the pzocua.,y;-af�fully ,
<br /> �the.C1ES report hris..beeu."filed as oz, the date of';this report. .' l defining the extent of contamination in soil and ground water atul �ass�as sr g
<br /> �, �, , impacts on sur%ace and/or ground water. l
<br /> LOCAL AGENCY ONLY , ~�j h �' ar' Remediation Plan - remodiatiun plan submitted evaluating long ten
<br /> To avoid duplicate'notikication pursuant`-t,� Health and Safety code Section � remediation options. Proposal and implementation schedule for ap)irogria`�
<br /> 251x0,5, a government eriplbyee should sign 'and-date the form in this block. remediation options also submitted. _Z
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<br /> A zzgnature herefdbes notimean that the lean has been.determined to pose a y Cleanup-Underway - implementation_of,remediation plan. �� #
<br /> sisgificant threat to iuzan health.or safety, only that notification . Post Cleanup Monitorinx in PxupresV- periodic ground water or at`her ..a...]
<br /> proledures have been followed if reTaired: y monitoring at site, as necessary, �16 verify and/or evaluate effedtiveness
<br /> A �rt / of remedial activities.
<br /> REPORTED BY Case Closed - regional board land local a6ency in concurrence that p0 7
<br /> Enter your name, telephone number,"and address. Indicate which party you /J' i further work is necessary at the site. 3x1 '
<br /> epresent and provide company or agenry name. -I }
<br /> _� J, - IMPORTANT: THE INFORMATION PROVIDED ON TEAS FORM IS INTENDED FOR GENERAL. �
<br /> RESACNSIBLE PARTY ti- STATISTICAL PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS'REPRESENTING'Tht'
<br /> Enter name, telephone numbsr, contact pe sr on, and address e'the party * OFFICIAL POSITION OF ANY GOVERIZ ENTAL AGENCY ' Fi
<br /> responsible for the leak. The resronsible party world normally be the tank
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<br />„ owner. ` "Z REMEDIAL ACTION I
<br /> '4 Indicate which action have been used to cleanup or remediate the le',*. ,, / �I
<br /> SITE LOCATION Descriptions of options follow: `, C3
<br /> Entex information regarding the tank facility. 'At a minimum,;you must J
<br /> provide the Facility name and full -address. , Cap Site - install horizontal impermeable layer to reduce rainfall
<br /> TMPLEMENTING AGENCIES y.r Containment Barrier'- install vertical dike to block horizontalmd. onf°
<br /> Later nitmes of, the local agency and Regional Water Quality Contrul Board_ contaminant.
<br /> involved. ` �±� `" ? _ P ",1 Excavate and Dispose remove contaminated sail and dispose in approved
<br /> ✓".,, d �` k I ' i' J' ,.... site,
<br /> SUESTRyCES r rV)LVFD �' a �.t �_. Excavate and Treat - remove contaminated soil and treat (includes spreading]
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<br /> Eatethe name,and � �i �
<br /> quantity'1©st of the hazar:daus substance involved. Rno�n �� `_, or land farming). � r
<br /> is provided fof,informaiion on tw"o substances if appropriate. If more than Remove Free Product - remove floating product from water table:
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<br /> two'suhstancesYeaked, .list the two'of must concern for cleanup, � «,,:'. " _ P=2 and Treat Groundwater - generally employed to remove dissolved �.
<br /> DISCOVERY/ABAT MENT Enhanced Biodegradation use of any available technology to promote
<br /> Provide information regal:ding the discovery and abatement of the leak. *� bacterital decomposition of CoTitaminants. �7
<br /> Replace Supply - Provide altgrn ative water supply to affected:paxties.
<br /> SOURC_ E ,CAUSE� 1i /� r ' t ? Treatment at Hookup - install water treatment devices at each dwelling of.
<br /> Indicate sourte(s) of leak. Check-box(es)'indicating cause of leak. . d-r other place of use.,,'
<br /> 4 Vacuum Extract - use pumps or blowers to draw a# through soil..41
<br /> CASE TYPE J 4 .,x vent Soil - bore holes in soil to allow volaLil'izatian of contaminants. ` , ?
<br /> r o - rJ I a ff
<br /> Indicate tht'case
<br /> hype category foi this leak. +Check one box only. Case° ° No Action Required - incident is minor, requiring no remedial action. p
<br /> type is based cmlthe most sensitive resource affected~ For example, if 4 4kb
<br /> both soil acrd gzeund water have been affected, case type will be "Ground z CM ENTS - bee this space to elaborate on any aspects of the incident./.
<br /> Nater". lndic� e "Drinking Water" only if one or more municipal or ��
<br /> fr7 dom6stic water wel.s have actually been affected. A "Ground Water" SIGNATURE -!Sign the foYm in the space provided.
<br /> V designation;d(�es.:n t imply that the affected water cannet be, or is not, I ;t �y e
<br /> used for drihkiing water„ but only that water wells have notjyet been DISTRIBDTIOk
<br /> affected. It is'understaod that case type may change upon further Tf the form is completed 41y the tank owner or his agent, retain th4,11ast copy
<br /> investigation. + .. N # t P _' and forwarditheremaining copies intact to your local tank permitting akency
<br /> for distribution. •+
<br /> CURRENT STATUS 1. Original - Local Tank Permitting Agency *
<br /> Indicate the category which best describes the current status of the case, 2- Regional Water Quality Control Board 1 .
<br /> Check one hoxt:6ri7.v' Thefresponse should'he relative to the�case type. For '' 3. Local Health Officer. and County Board of Supervisors or their'designtDe to '
<br /> exacnple, if case type is "Ground Water",4 then--'Current Status should refez "41 zeeeiva"Proposition 65 notifications. Y
<br /> to the statu'sj;o ,the ground water investigation or cleanup,.as opposed to., 4. -)caner/responsible p_'rty, k w{
<br /> that of. soil.Descriptions of options follow: d 1!
<br /> No Action;Taken - No action has been,taken-by responsible party beyond, "� !
<br /> initial r4port of teak.
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