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INSTRUCTIONS EVERtGENCY Leak Being Confirmed - Leak suspected at site, but has not been confirmed. Indicate whether emergency response- personnel and etiuipment were involved Preliminary Site Assessment Workplan Submitted - workplan./proposal at any time. Sf 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 (DES) at 2800 Meadowview Road, water has been, or will he, impacted as a result of the release. Sacramento, CA 95032. Copies of the OES report form may be obtained at Preliminary Site Assessment Underway - implementation of workplan. your local underground storage tank permitting agency. Indicate whether 'Pollution Gharecterization - responsible party is in the process of fully the OES report has bee: filed as of the date of this report. defining the extent of contamination in soil and ground water and assessing i:rpactS On surface and/or ground coater. LOCAL AGENCY- ONLY Remediation Plan - remediation plan submitted evaluati:.g long term To avoid duplicate notification pursuant to Health and Safety code Section remediation Options. Proposal and implementation schedule for appropriate 2518U.5, a government employee should sign and date the for, in this bloc',. remediation options also submitted. A signature here does rot mean that the leak has been detemined to pose a Cleanup Underway - implementation of remediation pian. 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 Closet', - 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. euresent and provide company or agency nae. IIMPORTANT: THE INFORMATION PROVIDEC ON THIS FORM, IS INTENDED FOR GENERAL Em SPONSIBLF. PARTY STATISTICAL F`RPOSES ONLY AND IS NOT TO BE CONSTRUED PS REPRESENTING THE Enter name, telephone number, contact poison, and address of the Party OFFICIAL POSITION OF ANY GOVERNMENTAL AGENCY responsible for the Leak. The responsible party would normally be the tank owner. REt-IEDIAL ACTION Indicate which action have been used to cleanup at remediate the leak. SITE LOCATION Descriptions of options follow: Enter information regarding the tank facility. At a minimum, you must provide the facility name and full address. Can Site - install horizontal impermeable layer to reduce rainfall infiltration. IMPLEMENTING AGENCIES Containment Barrier - install vertical dike to block horizontal movement of Enter names of the local agency and Regional Wate_ Quality Cont--Ol Beard contaminant. involved. Excavate and Dis.ose - remove contaminated soil and dispose in approved site. SUBSTANCES INVOLVED Excavate and Treat - remove contaminated soiland treat (includes spreading Enter the name and quantity Lost Of the hazardous substance invcL••ed. Room or land farming). is provided for information on two substances it appropriate. If more than Remove Free Product - remove floating product free water table. two substances leaked, List the two of most concern for cleanup. Pump and Treat Groundwater - generally employed to remove dissolved contaminants. DISCOVERY/ABATEN@NT 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 T-reatmant at Hookup - install water treatment devices at each dwelling or Indicate sources) of leak. Chock boz(es) indicating cause of lc-z.-s. other place of use, Vacuum Extract - use pumps or blowers to draw air through soil. SE TYPE Vent Soil - bore holes in soil to allow volatilization of contaminants. Indicate the case type category for this leak. Check one box only. Cane No Action Required - incident is minor, requiring no remedial action. type is based on the most sensitive resource affec'.ed. For example, - both soil and ground water have been affected, case type will be Ground CIX-1-1ENTS - Use this space to elaborate on any aspects of the incident. Water". indicate "Drinking Water" only if one or more municinal or domestic water wails have actually been affected. A "Ground 'Pater" SIGNATDRE - Sign the forin 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 DIS.'RIBUTION affected. It is understood that case typemaychange upon further if the form is completed by the tank owner or ]:is agent, retain the last copy investigation. - and forward Lite remaining copies intact to your 'local tank permitt_ng agency for distribution. CURRENT STATUS I. Original - Local Tani: Permitting Agenr-v Indicate the category which best describes the current status Of tLe case. 2, tate Water Res...ces Control Board, Division cf Clean an Water Programs, Check one cox only. The response should be relative to the case tvee. For Underground Storage Tank Program. F.O. =oa 944^I2 Sacrament., CA 94244- exsiple, if case type is "Ground Water", then "Current Status" should refer 2120 to the status of t::e ground water investigation or cleanup. as opoosed to 3. Regional 'Water Quality Control Bard that of =ell , Descriptions of options follow: f. Local Heaitit Officer and County Board cif Supe_-visr=, cr their designee to receive Proposition 65 notification. No Action Texan - No .,tier her bean taken by responseibLe party heyu.id _. O:,ner,'re=.p_nsitle party. initial -,pert of lack.