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INSTRUCTIONS
<br /> EMERGENCY
<br /> Indicate whether emergency xespcnse personnel and a t, Look Baine Confirm d - Leak syspectetl at site, but has not been confirmed.
<br /> at any time. If so, a Hazard,,= M - 9"=1?mert weze invo_ ed Prelimina Site Asses ' W gno ' h
<br /> with the State Office of Emcrg_ . aterial Incident P.eport should be filed - 'tt - workplan/proposal
<br /> �n ca Services (OES) at 2800 Meadowview Read, 4'u-s ted c£/s.inmi rte¢ by responsible party to determine whether
<br /> Sacramento, CA 35832, .Copies of c're CES re or water has been, or will be, impacted as a result of the release. ground
<br /> YO ur local urdergrovud sto_a e tank P form may be obtained at Pxeli:rinary Site As�essTen' and
<br /> the OES e ort has neon. _ g permitting agency, Indicate whether Pollution Craracte-ization - respvasibtemparty lamentationtoQ workplan.
<br /> r F filed as of the date of this report.
<br /> - 3efining Ute extent of contamin tion in soil and ground wateress andoassessing
<br /> full
<br /> LOCAL AGENCY ONLY impacts on surface and/¢r grouod water.
<br /> To avoid duplicate notification pursuant to Health and Safety code Section Remedy-ten P1ar. remediation plan submitted evaluating long term
<br /> 2.,1IIU.5, a government emuloyee should sign and date the form in this bloc's. - remedfatfon eptipns. Proposal and
<br /> A signature here does Oct mean that the leak has been determinedto
<br /> remediation options also submitted. e for appropriate
<br /> hum
<br /> significant threat to an health or safety, only that notificationpose a imulementaticn schedule
<br /> - implementation of remediatiplan.
<br /> on
<br /> ear,
<br /> ;2 have been followed if required. - Post Cieano Mon'to in
<br /> moniespiing at site, as necessaProry ress - Periodic ground water or other
<br /> REPORTED BY -' Of remedial ry, to verify and/or evaluate effecti
<br /> activities. veness
<br /> Entex your name, telephone- number, and address. Indicate which Case Closed - regional board and local agency in concurrence that no
<br /> resent and providn company or agency name. P"arty you further work is necessary at the site.
<br /> PONBIBLE PARTY IMPORTANT: THE. INFORMATION PROVIDED ON THIS FORM IS INTENDED FOR GENERAL
<br /> Enter name, telephone number, contact -rty STATISTICAL PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS ENDED FOR GE THE
<br /> responsible for the ak. The responsible Partywouldenormallyebeathe tank OFFICIAL POSITION OF ANY GOVERNMENTAL AGENCY
<br /> owner.
<br /> REMEDIAL ACTION
<br /> SITE LOCATION Indicate which action have been used to ape
<br /> Enter information regarding the tank facility. Descriptioiis,of options follow: -cleanup or remediate the leak.
<br /> provide the facility name and full address. A., a minimum, you must -
<br /> Can Side - install horizontal impermeable Layer to reduce rainfall
<br /> IMPLEMENTING AGENCIES - infiltration.
<br /> Entex nam— esof the local agency and Regional Wate_ Quality .Control Board Containment Barrio-
<br /> involved. vertical contaminant.
<br /> '- Excavate and Dispose - remove contaminated soil and dispose in a
<br /> SUBSTANCES INVOL4D - site. ,,.roved
<br /> Entex the name and cuantity lost of the hazardous substance fovolved. Room Excavate ar.:I Treat - remove contaminated soil and treat (too lodes sane adic;g
<br /> is provided for information on two substances i£ appropriate. If more than or land £arming).
<br /> two substances Leaked, list the two of most if
<br /> for cleanup. Remove Free Product - remove floating -
<br /> Puma and Treat G- d- Product from water table.
<br /> DISCOVERY/ABATEMENT t - generally employed to remove dissolved
<br /> contaminanL'.
<br /> Provide information regarding the discovery and abatement of the leak, enhanced Biodegradation - use of any available tecnnniogy to promote
<br /> bacterial decomP osi ti on of contaminants.
<br /> Indicate sources) of leak.
<br /> SOURCE/CAUSE Replace Supply provide alternative water supply to affected parties,
<br /> Check box(es) indicating cause of leak. Treatment at Peckap - install water treatment devices at each dwelling or
<br /> _ ocher place b.—use.
<br /> SE TYPE Vacuum Exti - use pumps or blowers to drew air through soil, -
<br /> ndicate the case type category for this leak. Check one box only. Case Vent Soil lots holes in sail to allow r-olatiL
<br /> type is based on the most sensitive resource affected. For example, i£ No Action Re nation of contaminants
<br /> andto
<br /> is minor, requiring no remedial action.
<br /> both soil Indicate
<br /> ground water have been affected, case type will be 'Ground -
<br /> Water". Ilidi r-ate "Driiiking Water' only if one or more municipal or CO:`MENTS - Use this space to elaborate on any aspects of the incident,
<br /> domestic water wells have actvaliy been -££ectad. A more
<br /> Water"
<br /> designation deer not IMPLY that fire affected water cannot be, or is net, SIGNATURE - Sign the form in the space sized for drinkin- P provided.
<br /> g water, but chat
<br /> -that water wells
<br /> cha have not yet been
<br /> affected It is understood ti�at case t DISTRIBUTION
<br /> investigation, YPe may upon further If the four is "'tOleted by the
<br /> tOwner or h
<br /> and forward the braining con es it act to you-- local aeiter. cet in thenglast
<br /> ccopy
<br /> CURRENT' Si ATL ' fez < stub ._on.
<br /> Indic at th category which ba.,g descr bes tho correct statusof U'!- 1. ncy
<br /> prig-na I.r al Tank Fem+tong Ag n.
<br /> Check oto hO.- or1.} Tho recronse should be a case. 8. C W3„ei ke�oarca - en trv'
<br /> example, if .c t relative to the cos Lupe. Pox - Road 'i is n of Clea., W' ter Frcgra:ms
<br /> ye i., coag 4jater - en 'Cut ant Statu should refer Lnd._givw i. tomaga Tank Progra^ 0, pas -4..212, Sac -am:antc. CF 9A244
<br /> to the t a .us o£ the ground Neter inn s 2.2U
<br /> that p. :,o i'_. Do cripi..ions f - ga .m-vr cl=anup as opposed to - z, Fog+ouai bl. r
<br /> Options ons all cpm- Qilalit, Control Board
<br /> 4. Loma H v. l iffyler and County board of Super isors
<br /> Ni Fe ion T�.c n Nc act h .r. b e' r is F. m i-„ioa 6u ctifiea th r a vg*:ec to
<br /> I Li 1. _ t,.: _ ..aR en by roc po psi bt patty bw_:.d tion...
<br /> �. :ble party.
<br />
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