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INSTRUCTIONS EMERGENCY Ind/eats whether emergency response pereannel and aqui pnent were involved Prelimluta Site Assessment Work Dlan Sulanilted winkplan/pnnimsal .t any Ll". If Be. a R.zerdous Material Incident Report t should Imo filed raquesl.ad of/suleitted by responsible party to determine whether ground with the State Office of Emergency Service. (OLS) at 2800 Meadowlew Road, water has been, or will be, impacted as a iesolt of the release Sacramento. CA 95832. Copies of the OtS report form may tie nbtaioad at ProLiminan Site Assessment dhidetwn - ImplasmuLatlrm of workplan. TOOK Intel underground storage tack permitLibR agency bolicate whei.Fer Pollution Cherecterization - rosponsibte party in in the process of fully the IES report has bean filed as of tam date of this report defining the extent of rmt.minal-ion in soil and ground water and aaseseins impacts on surface and/lir ground water II�C Li-AGENCY ON RemadieLicn Flan riw�ediaLiou plan :uMnitted ae.1u.ttu9 long term To avoid dupllcate mtifieation ImisuanL to Nealth and Safety code :iolt'Lul remediation options. Proposal and implementation schedule for appropriate 25180.7, a designated government employee should sign suit date Like Imo in remediation options also submitted. this block. A signature here dues not mase, that the leak has been Cleanup Umierway - implementation of remediation plan. determined to pose a sigrilficant threat to human health or ufety, only Post Cleanup Monitoring in Pro)L,pss - perrndit, ground water or other that notification procedures have been followed if requiredmonitoring at site, as necessary, to verify .raid/or evaluate effectiveness of remedial activities REPORTED BY Cass Closed - regional board slid local smartly in cunrurrence that no Enter your name, telephone number, and address. Indicate which party you further work Is necessary at the sit*. represent and provide company or agency nem. IMPORTANT: THE INFORMATION PROVIDED ON 7815 FORM IS INTENDED FOR GENERAL RESPONSIBLE PARTY STATISTICAL PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REPRESENTING THE Enter time, telephone number, contact person, and address of the party OFFICIAL POSITION OF ANY GOVERNMENTAL AGENCY responsible for the leak. The responsible party would normally be the tank owner. REMEDIAL ACTION Indicate which act/on have been used to cleanup or reamdiate the leak. SITE LOCATIOI Descriptions of options follow: Enter information regarding the tank facility. At a minimum, you moat provide the facility name and full address. Cao Site - install horizontal impermeable layer to reduce rainfall Infiltration. IMPLEMENTING AGENCIES Contoit t Barrier - install vertical dike Lo block horizontal movement of Enter nae of the local agency and Regional Water Quality Control Board contaminant. Involved. Excavate and Dispose - remove contmtnatsd soil and dispose in approved site. 311837ANCES INVOLVED Excavate and Treat - remove contaminated soil and treat (includes spreading Enter the news and quantity lost of the hazardous substance involved. Roam or tend farming). Ie pcuvldsd for Information on two substances if appropriate. If more than Remove Free Product - remove floating product from water table. two substances leaked, list the two of mat concern for cleanup. Pump and Treat Groundwater - generally employed to remove dissolved contminants. DISCUMT/ABATE ENT Enhanced Biodegradation - use of any wettable technology to promote Provide information regarding the discovery and abatement of the teak. bacterial decomposition of contaminants. Replace Supply - provide ellernative water supply to affected parties. SOURCE/CAUSE Treatment at RookuD - install water Lraatimn. devices at each dwelling or Indicate source(s) of leak. Check bogies) indicating cause of Leak, other plecs of use. Vacuum Extract - use pimps or blowers to draw air through soil. CASE TYPE Vent Soil - bore holes In soil to dhow volatilization of contaminants. Indicate the case type category for this leak. Check one box only. Case No Action Rewind - Incident is minor, requiring no remedial action. type I, based m the met sersltive resource affected. For example, if both soil and ground water hove bean affected, cue type will be "Ground COMMENTS - Use this space to elaborate on any aspects of the incident. Water". Indicate "Drinking later" only, if ane or mrs municipal or domestic water wells have actually been affected. A "Ground Nater" SIGNATURE - Sign the Core In the space provided. designation do" 1mat imply that the affected water cannot be, or is not, used for drinking motor, but only that water tells have not yet been DISTRIBUTION affected. It is understood that case type may change upon further If the form is completed by the tank inner or his agent, retain the last copy Investigation. and forward the remaining copies Intact to your local tank permitting agency for distribution. CXIM STATUS I. Original - Local Tank Permitting Agency Indicate the category which bast describes the current status of the case. 2. State Water Resources Control Board, Division of Loans and Grants. Check one box only. The response should be relative to the case type. For Underground Storage Tank Program, P.O. Box 944212, Sacramento, CA 9e2e4- exmple, if cue type is "Ground Nater", than "Current Status" should refer 2120 to the status of the ground water investigation or cleanup, as opposed to 3. Regional Water Quality Control Board that of soil. Descriptions of options follow: i. County Board of Supervisors or designee to receive Proposition 65 natifkcations. No Action Taken - No action has been taken by responsible party beyond 5. Owner/nesponsible party. initial report of leak. Leak Beim Confirmed - Leak susperted at site, but hes not. been confirmed.