UAR/PROP 65_PRE 2019 - Laserfiche WebLink

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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 Worknlan Submitted - workpian'propcsal at any time 'f so, a Hazardous Material Incident Report should be filed requested o£/submitted by responsible party to determine whether ground with the State Office of Emergency Services (OES) at 2800 Meadowview Road, water has been, or will be, impacted as a result of the release. Sacramento, CA 95832. Conies of the CES report form may be obtained at Pnelrninary Site Assessment Underwav - 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 ceen filed As of the date of this report. - defining the extent of contamination In soil and ground water and assessing impacts on surface and/or ground water. LOCAL AGENCY ONLY - Remed_aticn 'Plan - remediation plan submitted evaluating long term To avoid duplicate notification pursuant to Health and Safety code Section remediation options. Proposal and implementation nchedu Le for appropriat<_ 25180.5, a government employee should sign and date the farm in this Klock. - remediation options also submitted. A signature here doea not mean that the leak has been determined to pose a Cleanup Underwav - 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 beer. 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. present and provide company or agency name IMPORTANT: THE INFORMATLON PRGVIDEC ON THIS FORM IS INTENDED FOR GFhiRAI. ESPONSIBLE PARTY STATISTICAL PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REPRESENTING THF 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 tank 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. At a minimum, you most provide the facility name and full address. Can Site - install horizontal impermneable layer to reduce rainfall Infiltration. I14PLEMENTING AGENCIES Containment Barrier - install vertical dike to black horizontal movement of Enter names of the local agency and Regional Gates Quality Control Board contaminant. involved. Excavato ar;d Dispose - remove cort.a,minated soil and dispose in approves sire. SUBSTANCES INVOLVED Excavate and Treat - remove contaminated soil and treat (includes spreading Enter the name and quantity Lost of the hazardous substance involved. Room or land Earning). is provided fox information on two substances if appropriate. If more than Remove Frea Product - remove floating product from water table. two substances leaked. List the two of most- concern for cleanup. Fume and Treat Groundwater - generally employed to remove dissolved contaminants. DISCOVERY/ABATEMENT Eninanced Biodegnadaticn - 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. SOURCF/CAUSE T=_eatnent at Hpeknp - install water treatment devices at each d«elling or ndicate soutce(s) of Zeit. Check be,(es) indicating cause of lest. other Flare of use. Vacuum Extract - use pumps or blowers to draw air through soil. SE TYPE Vert SOLI - bare holes in soil to allow vo latiii za ti on of containrnants. Indicate the case type category for this leak. Check one boy only. Case No Action Required - incident isminor, requiring no remedial action. type is based on the most sensitive resource affected. For example, if both soli and ground water have been affected, case type will be "Ground COM-LENTS - Use this space to elaborate on any aspects of the incipient. Water". Indicate "Drinking water" only if end or more municipal or domestic water wells have actually been affected. A "Ground Water" SIGNATURE - Sign the form in the space provided. designation docs net i.mm:ly 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 +hot case type may change upon further if the form is completed by the,tank owner or his agent, retain the last copy investigation, and forwerd the remaining copies intact to your ictal tankpaxmitting agency for :iistribu-ion. CURRENT STATUS 1. Original - Local Tank Permitting Agency Indicate the category which best describes Lhe current status of the case. c State Were, R=so-„roes Control Board, Division of Clean Water Programs. Check one bot only. The ecsponse should be r=-lative to the case tvpe. For Underground Storage Tank Program, P.O. no, 944212, S.=.crameeatu, CA 94R44- example, if cane type " "Grp,md Water", theii "Current Stu Les" shacid refer 2120 Lo the statue c£ the, ground water investigatrn', or cleanup. as opposed to 3. R>S�pnal Water Qea'ity Control Board that of soil re ___adcns -,f op-.ions £a Llow-: 4 i.ccai Ha Officer and Ceuntr Board of Suuer:isors or their designee to recei+ :oci on tis notifications.. - N- Aciicn T � -n Nc, aet,r, ..0 ro ...: tai.zn cv responsible nartr- 55 'v nr:ire - r.s ihl= party.