UAR/PROP 65_PRE 2019 - Laserfiche WebLink

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- l! INSTRUCTIONS EMERGENCY Indicate whether emegex:cy response personnel and a Leak Being COnfi Pd at any time. sb a-i;azaresp Material Incident R point were involved Leak suspected at site, but has not been confirmed. a the State Off Preliminary $ite Assessment Workplan Submitted Sac ice a� Emergency Services (OES7 at 280D Meadowview Road, requested of/submitted by responsible partytto determrne1whether' ground Sacramento, CA 95832. Ccpies of,tl4a O re water;iias been, or will be, impacted as a result of ^e release-- pour local undf!rgrpund storage tank permitting_report, be obtain94 at Prekim y Site "ssessment Umpactednderway - i -r the QES report has t g g Y Irt.,, te•whcther PoZlut3on Ch 8cterization - responsible -emertati� f workl7Tan.. bse�l f2..ed as of the ate of this"reg"rt ' ? defining t.e extent of contamination in seiltands in process of fully LOCAL AGENCY . y- z impa is on surface and/or ground water, g cy'd water and assessing c avoid duplicate natty , 251805, a = oyee parsuant1to Health and•,Safety code Section Remed3,atioh�Plan - remediation plan submitted evalua-°*;g government should s;gn and date the form in t remediation options. Proposal and implementation sc =du leofor ropriate A signature he6'doe riot n can tfiat th his ose a. significant threat to y s leak has been determined to pose"a Gleams p Uh options also submitted. non health or safety, Snly that ngtAficatior. Cleanup Untterwav - implementation of remediation . Procedures have been t4e11owed if required. Post Cleanup Monitorin in ro�ress periodic p G monitpr�ng �t site, as necessa p gTO n3 water or other REPORTED By ry, to verify and/or evaluate effectiveness Enter of remedial �ctiv tees. Your name,-telephbD.e number and`address. Indicate' - Case Closed regional board and local agency in concurrence thaH no represent and provide company or agency name. �w4�ch pmrty you further work is t}ecessary at the site. RESPONSIBLE PARTY : y: IM°ORTANT: THE INFORMATION PROVIDED ON THIS FORM IS IN EN ED FOR GE16$RAL Enter name, telephone number, contacr person, and address the party % STATISTICAL PURPOSES y responsible fOl' the leak. •� AND IS NOT TO BE CONSTRUED AS RE?RESENTINv THE owner, The resgonsilXle pait would normally be the tank OFFICIAL POSITION OF A,*IY y G�NTAL AGENCY SITE REMEDIAL ACTION TE_ LOCATION TION -. Enter information regarding the tank £agilityIndicate which actioxi have been used to cleanup or remed_a>a the 1e2 ' At a minimufe, you must =j Descriptions of options follow: Provide the facility,'Lgme and full address. Cap Site - install horizontal impermeable layer to re„=_e IMPLEMENTING AGENCIES: tiinfa Enter names of the local a enc infiltration. agency and Re Containment Barrier install vertical dike to block r 2ohtal'tovement of involved. gional Kater Quality Control Boara - �: .� contaminant. SUBSTANCES INVOLVED Excavate and Dispose - remove contaminated soil and . :.s_ase.in 413 roved Enter the name and qt7 tity Idst of the Y,azardous suhstanc_'invoived. Room site. Excavate and Treat - remove contaminated soil and tre%at (include spreading d3 is provided for inforna:tion I: two sthL--ances_ if agpraprnce' If more than °T Land farming). two substances leaked, fist tAe two of Most concern for cleanup. Remove Free Product - remove floating ' Pump and Treat product from water talSle. DISCOVERYlABATEMENT contaminants. Groundwater - generally employed to remove dissolved Provide information re''a'rdin the discovery g g Enhanced Biodegradation - use of any available techn .c. t - t^ ry and- of the leak. bacterial decomposition of contaminants. gy pr°c?ate SOURC�SE ..+ - •-- Replace Stippl4 ,_ •+� Indicate source s �} - p;Ovide alternative water supply t affect#�Ct ( ) pf lealv. `--Check�box(es� indicting cause of leak. Treatment at Hook u4� - install water treatmentdevicesa- parties. CASE TYPE Other place of use. - ling or Indicate the case type`category for thise Vacuum Extract - use Pumps or blowers to draw air thrO;zgh s$il. type is based on the most,sensitive resource hf£ec ed. For example, i£ Vent Soil - bore holes in soil to allow volatilizatto of aka Check one bdx only. Caso No. Ac ion Required - incident is minor, contaminants. both soil and ground wader I-Ve'-been affected, case requiring no _emedi�l action. Water". Indicate "Dri: i.ng Sd�dtex^. only if one.or rrotype Wn i be or - domestic Otter wells have actually been affected. A "Ground Water" COMMENTS:—Use this spacE to elaborate on any aspects of e incident.: design does not imply ttat the affected water cannot 4 ` "tee - SIGNATUR&as Sign the form i-n the space provided. Used for � x be, or is not, r illi ng n t*r-, but'monly that water we.Lls have not yet been i a fected r is undp�gtood that case DiSTRIBUT`t3N y P, may change uppn=futther y If the forty. is completed by the'tank owner or his agent, re ain ' u j and forward the remaining copies intact to ��ne•�st copy ' R SiA 3 for dos aibuthe Your local tank perm, Tn lcaL the-tlate orV -''"' - - - - �. agency g Y ta}�%ph belst describes the current of the case. 1. Original- Local flank Permitting Agency ex ck,one-bcx only. Tbi@ response should-be relative to the base t 2. State Slater Resources Contrql Board, Division of Clean Water: Programs � l ek'mp e if case type:-'sl "Ground Weter•' type. . For Underground Stora e Tat3k' r tO the status,of the then "Current Status should ret'- g o�ram, P.O. Box 944212, Sacramento, CA 94244- that fir£ s�z round water investiga ion or clear., " as " 212D 1. Descri = p r. pposed to p ns3of o tions follow, 3. Regional Water ?uAiity Cart-dl Board 4. Local Health Offices and C ctxo• en - hd action has been-rake by responsible party bey". tY Board of Supervisors „r t_ie�r 1 receive PropositioTr E5 D.Otdl cations. �� sigi;ee to int ..al t'eport of leak: � _ ° � 5. Owner(resgonsible`pprty. .