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INSTRUCTIONS EMERGENCY Leak Being Confirmed - Leak suspected at site, but has not been confirmed. Indicate whether emergency 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 of/submitted by responsible party to determine whether ground with the State Office of Emergency Services (OES) at 2800 Meadowview Road, water has beer., or will be, impacted as a result of the release. Sacramento, CA 95832. Copies of the CES report form may be obtained at Preliminary Site Assessment Underway - implementation of workplan. your local underground storage tank permitting agency. Indicate whether Pollution Characterization - responsible party is in the process of fully 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 impacts or. surface and/or ground water. LOCAL AGENCY ONLY Remediation Plan - remediation plan submitted evaluating long term To avoid duplicate notification pursuant to Health and Safety code Section remediation options. Proposal and implementation schedule for appropriate 25180.5, a government employee should sign and date the form in this block. remediation options also submitted. A signature here does not mean that the leak has been determined to pose a Cleanup Underway - implementation of remediation plan. significant threat to human health or safety, only that notification Post Cleanup Monitoring in Progress - periodic ground water or other procedures have been followed if required. monitoring at site, as necessary, to verify and/or evaluate effectiveness of remedial activities. REPORTED BY Case Closed - regional board and local agency in concurrence that no Enter your name, telephone number, and address. Indicate which party you further work is necessary at the site. represent and provide company or agency name. IMPORTANT: THE INFORMATION PROVIDED ON THIS FORM IS INTENDED FOR GENERAL RESPONSIBLE PARTY STATISTICAL PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REPRESENTING THE Enter name, telephone number, contact person, and address of the party OFFICIAL POSITION OF ANY GOVERNMENTAL AGENCY responsible for the leak. The responsible party would normally be the tack owner. REMEDIAL ACTION indicate which action have been used to cleanup or remediate the leak. SITE LOCATION Descriptions of options follow: Enter information regarding the tank facility. .t a minimum=, you must provide the facility name and full address. Cap Site - install horizontal impermeable layer to reduce rainfall infiltration. IMPLEMENTING AGENCIES Containment Barrier - install vertical dike to block horizontal movement of Eftsr namQMPof the local agency and Regional Slater Quality Control Board contaminant. involved. Excavate and Dispose - remove contaminated soil and dispose in approved site. SUBSTANCES INVOLVED Excavate and Treat - remove contaminated soil and treat (includes spreading Enter the name and quantity lost of the hazardous substance involved. Rood or land farming). is provided for information on two substances 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 technology to promote Provide information regarding the discovery and abatement of the leak. bacterial decomposition of contaminants. - Replace Supply - provide alternative water supply to affected parties. SOURCE/CAUSE Treatment at Hookup - install water treatment devices at each dwelling or Indicate souxW 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. For example, if both soil and ground water have been affected, case type will be "Ground COt-f-ENTS - Use this space to elaborate on any aspects of the incident. Water". Indicate "Drinking Water" only if one or more municipal or domestic water wells have actually been affected. A "Ground Water" SIGNATURE - Sign the form in the space provided. designation does not imply that the affected water cannot be, or is not, used for drinking water, but only that water wells have not yet been DISTRIBUTION affected. It is understood that case type may change upon further If the form is completed by the tank owner or his agent, retain the last copy investigation. and forward the remaining copies intact to your local tank permitting agency for distribution. CURRENTSTATUS 1. Original_ - Local Tank Permitting Agency Indicate the category which best describes the current status of the case. 2. State,Water Resources Control Board, Division of Clean Water Programs, Check one box only. The response should be relative to the case type. For Underground Storage Tank Program, P.O. Box 944212, Sacramento, CA 94244- example, if case type is 'Ground Water", then "Current Status" should refer 2120 to the status of the ground water investigation or cleanup, 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 or their designee to receive Proposition 65 notifications. No Action Taken - No action has been taken by responsible party beyond 5. Owner/responsible party. initial report of leak.