UAR/PROP 65_PRE 2019 - Laserfiche WebLink

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INSTRUCTIONS o _ EMERGENCY • Leak Being ConflrrAbd - Leak suspected at site, but has not been confirmed. Indicate whethet emdrgency response personnel and equipment were involved Preliminary Site Assessment Workplan Submitted - workplan/proposal at any time. If 'so, a..Hazardous Material Incident Report should be filed requested aflsunmitted by responsible party to determine whether ground with the State'Office of Emergency Services (OES) at 2300 Meadowview Road, water has been, or will be, impacted as a result o£ the release,-. _ Sacramento, CA 95832. Copies of ne OES zepoFt form aay be obtsined at Preliminary Site Assessment L'zdarwav - implementation of workplan_ Your local undergroungl•: tozage tarp Pollution Chdracterization - responsible party is in the pracess' af fully pe mittjrg agency. jndieateined atr the OES report has been filed as of the date of this report, - defining the extent of contamination in soil and ground water and assessing To avoid dupliscat impacts on-suY£ac.e and/or ground water. LOCAL AGENCY duplicate Remediation Plan - remediation plan submitted evaluating long term notifi4ation .pursuant to Health and Safety code Section remediation;options, Proposal and implementation schedule for appropriate 25180.5, a government erlpioyee Should sign and date the •form in this block.' remediation- options also submitted. A signature her® does mot' mean that the leak-has been determined to pose a Cleanup Underway - implementation of remediation plan. significant threat to human health or safety, only thet notification - Post.C•leanur Monitoring in progress - periodic ground water or other, procedures have been fgllowed if required. monitoring at site, as necessary, to verify and/or evaluate effectivenep REPORTED BY of remedial activities. Case Closed - regional board and local agency concurrence that no Enter your name,,_teleghone number, and address, indicate which arty you further work is'necessary at the site. r RESPONSIBLE PARTY IMPORTANT: THE INFORMATION PROVIDED ON THIS FCk-M IS INTENDED FOR GENERAL` STATISTICAL PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REPRESENTING THE Enter mase, telephone number, contact person, and address of the party OFFICIAL POSITION OF ANY GOVERNI�NTAL AGENCY responsible for-the leak. The zpsponsi le'party would normally be the tank owner. REMEDIAL ACTION SITE ZOCATION Indicate which action have been used to cleanup or remediate the leak.Enter information regarding the'tank facility. At a minimum, you must Descriptions of options•foliow: provide the facility n ae and full addre s. ` Can Site - install horizontal impermeable layer to reduce,r-ainfall infiltration. r names off thethe local agency IMPLEMENTING IES� Containment Barrier - install vertical dike to block horizontal movement of Enteand Regional Water Quaiity Control Board contaminant. involved. Excavate and Dispose - remove contaminated soil and dispose in approved'' SUBSTANCES INVOLVED site. - Enter the name and quatrtity lost of the Excavate and Treat - remove contaminated soil and treat (includes spreading �. hazardous suhstance involved. Room or land farming), is provided for inform4tion'on two sub`stahces if appropriate: If more than Remove Free Product - remove floating product from water table. two substances leaked '''list the two of most concern for cleanup. Pump and Treat Groundwater - generally employed to remove,dissolved �. contaminants DISCOVERY/ABATEMENT ~ . _ Enhanced Biodegradation - use of any available techrolagy,to promote F Provide information regarding the.discovezy and abatement.of the lea_�c. ` bacterial decomposition of contaminants. SOURCEICAUSE r r Replace Supply - provide alternative water supply to affected parties. Treatment at Hookuu - install water treatment devices at each dwelling of Indicate source(s) of leak. Check` box(es) indicating cause of leak, other place of use. � Vacuum Extract - use pumps or blowers to draw air through soil.; CASE TYPE _ Vent Soil - bore holes in soil to allow volatilization of contaminants. Indicate the case type category for this leak. Check one box only. Case No Action Required - incident is minor, requiring no remedial action. type is based on the most: sensitive resource affected. Fqr example, if both soil and ground water have been affected, case ,type will be "Ground COMMENTS - Use this space Eo elaborate on any aspects of the incident. , k. Water". Indicate "Drinking (later" only if one or more municipal or domestic water wells have actually been affected. A "Ground Water" SIGNATURE - Sign the £crm,in the space provided. designation does not imply thiit toe affected water cannot be, or is net, used for drinking water, but only-that water wells have not yet been DISTRIBUTION affected. It is understood that care t r �- type may change upon further If the fora is com leted by the tank other or his agent, retain-the last copy investigation. 'and forward the remaining copies intact to Your local tank perciitting agency. for distriiution. CURRENT STATUS 1. Original - Local Tank Permitting Agency Indicate the category which )nest describes the current status of the case. 2. State Water Resources Control Board, Division of Clean Box 944212, Sacramente;'CA ams,Water Pz:ogr , a.s Check one box only. The response should'be relative to trip case type. For Underground Storage Tank Program, P.O. - example, if case type js "Graaind_Water". then "Current Status" should refer 2120 to the status of the ground is ter investigation or cleanJip, as opposed to 3. Regional Water Quality Control Board that of soil. Descriptions-of options follow: 4. Local Health Officer and County Board of Supervisors ortheir designee to receive Proposition .55 notifications. No Action Taken -'No action :'nes been taken by responsible-•party beyond Ocher/responsible party., .nidal report of leak. .. �'.