UAR/PROP 65_PRE 2019 - Laserfiche WebLink

Home Browse Search

INSTRUCTIONS EMEP RGENCY Indicate whether emergency res ome er"s;70nne1 and equipment Leak Being Confirmed - Leak suspected at site, but has not been confirmed. at any time. If so, a Hazardous Material Incident Re}�o tnshould bevfire`d Preliminary Site Assessment Workplan Submitted - workplan/proposal with the State Office of Emergency Services fOES) at�800 Meadowview Road, requested of/ submitted by responsible party to determine whether ground Sacramento, CA 95832, Copies of the OES report form ,watLP�as been, ar will be impacted as a result of the release.- Preliminary F ;nay be obtained at -" Preliminary Site Assessment Underway - implementation of workplan. your local underground storage talk perrsitting agency, Indicate whether the DES report has been filed as of the dace df this report. y Pollution Characterizatio*: - responsible party is in the procesan'js of fuli}c LOCAL AGENCY OT y defining the extent of contamination in soil and ground water and assessing -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 25280.5, a government employee should sign and date the form in this block. - remediation options. Proposal and implementation schedule for appropriate A signature here does not mean that the leak has been determined to ase a remediation options also submitted. p pp priate significant threat to human health or safety, p Cleamp Underway - im lementation of procedures have beer, followed if required- only t{iat notification - p remediation pian. ^ most Cleanup Monitoring in Prazrest - periodic ground water or other monitoring at site, as necessary to verify and/or evaluate effectiveness REPORTED BY of remedial activities. Enter your name, telephone number, and address. Indicate-which part Case Closed - regional board and local agency in concurrence that no represent and provide company or agency name. -- - y }ou further work is necessary at the site. RESPONSIBLE PARTY Enter name, IMPORTANT: THE INFORMATION PROVIDED ON THIS FORM IS INTENDED FOR GENERAL telephone number, contact perlon, and add of the part STATISTICAL PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REPRESENTING THE responsible for the leak. T - y OFFICIAL POSITION OF BONY GOVERNMENTAL, AGENCY owner. he responsible p;arty woul[ normally be the tank REMEDIAL ACTION SITE LOCATION Indicate which ac ion-have been used to cleanup or remediate the leaf. Enter information regarding the tank facility. Descriptions of options follow: regarding y. At a minimum, you must provide the facility name and full address. ". Cap Site - install horizontal impermeable layer to reduce rainfall IMPLEMENTING AGENCIES infiltration. _ Enter names of the local agency and Regional Water Containment Barrier - install vertical dike to block horizontal movement of involved, Quality Control Board contaminant. Excavate and Dispose - remove contaminated soil and dispose in approved SUBSTANCES INVOLVED site. Enter the name and quantity lost of 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 or land farming). two substances leaked, list the two of most concern for Cleanup. Remove Free Product - remove- f_oatir. floating product from water table. - Pump and Treat Groundwater - generally employed to remove'dissolved DISCOVERY/ABATtMENT contaminants. Provide information regarding the discovery and abatement of the leak, Enhanced Biodegradation - use of an available technology to bacterial decom ori y gY promote p tion of contaminants, SOURCE/CAUSE Replace Szpply - provide alternative water supply to affected parties. Indicate source(s) of leak. Check boxfes-) indicating cause of leak. other place.bf usg'- Treatment at Hookup - install water treatment devices at each dwelling or CASE TYPE Vacuum Extract --`use pumps or blowers to draw air through-soil. Indicate the case type category for this leak. Check one box only. Case Vent S-s-lonR bur hales in soil to al-low volatilization o£,cant type is based an the most sensitive resource affected. For example, if No Action Required - incident is minor, re ainants. both soil and ground water have been affected, case t quiring no remedial action. Water". Indicate "Drinking Water" onl ype will be "Ground CO MIENTS '- Use this space to elaborate on any aspects of the inciden.t. . y-)f one or more municipal or domestic water wells have actually been affected. A "Gra Water" designation does riot imply that the affected -water cannot, or is not, SIGhATUR$ Sign the,form in the space provided. used for drinking water, but only that water wells have ilot yet been affected. It is understood that.case type may change upon .further DISTR.IBUCN investigation. If the form is completed by the tank owner or his agent, retain, the last copy and forwaidxt_e remaiEing copies intact to your local tank permitting agency CURRENT T STATUS _ for distribution. Indicate the category which best describes the current status of the case. 2" Original Local Tark Permitting Agency Check one box on]- 2. Stage-Water Resources Control Board, Division of Clean Water Pro y. The response should be elative to the case type. -For Underground Storage Tank Program, F,O, Box. 944212, S grams' example, if case type is "Ground Water",- tbeh "Current Status" should refer to the status of the 2'20 acramyaxto, CA 94244- ground water invesig tion or cleanzpt. as opposed to that of soil. Descriptions of options ffl,Ow: 3- Regional 'nater Ku ?.ity Control Board 4. _ocal'Health Officer and County Board of Supervisors or t4ei2 designee to- No Action Take.n No action h ben receive Propos n 65 notifications.iuta?. iior + kypone Party beyond _ea... Cw er„(responsib party.