UAR/PROP 65_PRE 2019 - Laserfiche WebLink

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INSTRUCTIONS EMERGENCY - Indicate whether emergency response personnel and equipment were involved f Leak Being Confirmed'- Leak suspected at site, but has not been: confirmed. at any time. I£ so, a Hazardous Material Incident Report should be filed Preliminary Site Assessment Workplan Submitted - workplan/proposal with the State Office of Emergency Services (OES) at 28q.0 Meadowview Road, requested of/submitted by responsible party to determine whether .ground Sacramento, CA 9583 . Copies of the OES report form may obtained at water has been, or will be, impacted as a result of the release. Your local underground storage tank Preliminary Site...Assessment Underway implementatior. o£ workplan, g permitting agency. Indicate whether Pollution Characterization - res onsible the OES report has teen filed as of she date of this report. P party is in the prooess of fully defining the extent of contamination in soil and ground water and assessing LOCAL AGENCY ONLY impacts on surface and/or ground water. To avoid duplicate notification pursuant to Health and Safety code Section, Remediation Plan - remediation plan submitted evaluating long term 25180.5, a remediation options. Proposal and implementation schedule for ;appropriate governmeht employee should s'_gn and date the form in this block. A signature here does nou mean that the leak has been determined to ose a remediation options also submitted. significant threat to human health or safety, only that notification p Cleanup Underway - implementation of remediation plan. procedures have been followed if required. Post Cleanup MQnitor°ng in Progress - periodic ground water or other monitoring at site, as necessary, to verify and/or evaluate effectiveness REPORTED BY of remedial activities. AftEnteryour name; telephone number, and address. Ir;dicate which party you Case Closed - regional board and local agency in concurrence that no - represen`, and provide company or agency name. further work is necessary at the site. }f RESPONSIBLE PARTY•" IMPORTANT: THE INFORMATION PROVIDED ON THIS FORM IS INTENDED FOR GENERAL Enter name, telephone number, contact STATISTICAL PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REPRESENTING THE responsible for the leak. The responsible and address of the Party {Y OFFICIAL POSITION OF ANY GO9ERNMd;NTAL AGENCY owner. P party would normally be the anis REMEDIAL ACTION SITE LOCATION Indicate which action have been used to cleanup or remediate the leak. Enter information regarding the tank facility. At a mir.i:rram,•you must of options fallow: Provide the facility name and full address. Cap Site - install hoYizontal impermeable layer to reduce rainfall IMPLEtiTENTING AGENCIES _ infiltration. Enter at t}ie local agency' and Re Containment Barrier - install vertical dike to block horizontal movement of involved, Regional Water Quality Control Board contaminant. Excavate and Dispose - remove contaminated soil and dispose in approved SUBSTANCES INVOLVED site. Enter the name and quantity lost o£ the hazardous substance involved. Room Excavate and Treat - remove contaminated soil and treat (includes spreading is provided for information on two substances if appropriate. If more than Re ovelan £arming}, two substances leaked, list the twa_of most concern for cleanu Remove Free Product - remove floating product from water table. p. Pwn]2 and Treat Groundwater - generally employed to remove dissolved r. DISCOVERY/ABATEMENT contaminants, Provide information regarding the discovery and abatement of the leak, Enhanced Biodegradation - use of any available technology to promote bacterial decomposition of contaminants. SOUR-17 Replace Supply - prove alternative water supply to affected'parbies, idicat our_ ,s; of leak. Check boxies Treatrr nt at fRuo - �nsta'I water treatment devices at each dwelling or it:t eating cak_ ,e c_ eek- other place o£ use. CASE TtPE Vacuum Extract - use pumps or blowers to draw air through soil. Indica e t Vent So sl bore holes in soil to al he ease type category for this leak. Check one bei onlow volatilization of contaminants.ly. Case No Action Re:ruired - incident i type is based on the most sensitive. resource affected. For example, s miner, requiring no remedial action. Water". Indicate "Drinking Waterif both soil and ground water have beecen affected, case type will be "Grout;d " only one or more municipal or `COMMENTS - Use this space to elaborate on any aspects of the incident•`. actually been affected. A "Ground Water" domestic water wells have designation does not imply that the affected water cannot b6, or is not, SIGNATURE - Sign the form in the space provided, used for drinking water, but only that water wells have not yet been affected. .It is understood that case t DISTRIBUTION investigation. ype may change upon'�further If the form is completed by the tank owner or his agent, retain the last copy and"forward the remaining,copies intact to your local tank permittir1g agency CURRENT STATUS 'for distribution. Indicate the category which best describes the cUrrent status of the case. 2. OriStaginal - Local Tank Permitting Agency Check one box only. The response should be relative to the case type. For Division of Clear. Water Programs, example, if case t + t P Underground Storage Tank Program, P.O. Box 944212, Sacramento, CA 94244- ype is "Ground Water", then "Current Status" should refer 2120 to the status of the ground water invest.igation'or cleanup, as opposed to 3. Re ional Water that of soil. Descriptions of .options follow: g Quality Control Board 4. Local Health Officer and County Board of Supervisors or their designee to No Action Taken - No action h receive Proposition o5 notifications- has been tskei, by responsible party beyond 5. Owner/responsibleparty. i=;i tial rep;r`, of leak, r '