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INE'T"UCT ION S
<br /> =_K ENCY Leak Being Confirmed - Leak suspected at site, but has not beer, confirmed.
<br /> 1""ate W _�hpthoeqne-gencyares kon�',e personn6l and equipPreli-i-ainary Site Assessment Wqtkp1an,SubT-nittqd - workplan/proposal
<br /> ment were involved 'he- ground
<br /> at ally time. If s, a n rdcus iia. al !-kj�ident Report should be filed requested of/submitted by responsible party to determine whet
<br /> with the State Offs C y
<br /> -n FOES) at 2800 Meadpwv4ew Road, water has been, or w`11 be, impactedas a reFuLt of the release.
<br /> 3a4�ramento, CA ?1-832. Ul,le_s o f the
<br /> e ES report form irap be obtained at Preliminary Site Assessme'nt, Underway - implementation of workplan.
<br /> your local undergroundsgtank permittdrig agency- Indicate whether PoID.,,tion Characterization. - responsible party is in the process of fully
<br /> l�,
<br /> th, n
<br /> OES re-port his' aof -the date of this re�ort, ding the extent of contamination in sol' aj,d ground water and assessing
<br /> � s .efi--I mi
<br /> impacts on surface and/or ground water.
<br /> L,_- AL AGENC'! ONL%' Remediation Plan -- remediation pLau submitted evaluating long term
<br /> ediat on options. Proposal. and impLem-entat on schedule I r. ar ropriate
<br /> ?.' Health and Safety code Sjctior. r elt
<br /> To ovoid notilfic�,"on pursuant to
<br /> 25120.5, P ,ove_-Truent should sign and date the form in tb4s.block, remediation options also submitted.
<br /> A signature her? �L,e odetermined t MU�111 that the leak has been dete ined to pose a Cleanup Underway - implementation of remediation pLan.
<br /> significant, threat to 'hi.-4an hoalth or safety, only that notification Post Cleanup Monitoring in Progress - periodic ground water or otger
<br /> e U�_ i Lu effectiveness
<br /> proc eQures have h6ei- fo 1. J i I req- 1--e,-. monitoring at site, as necessary, verify and/or eva ate effecti n
<br /> of remedial activities.
<br /> RJEPMTED BY Case Closed - regionaL board and local agency in concurrence that TIO
<br /> Eater your name, t_e!.&phonc rmf,.oer, and add-rIess. Indicate which part-T you further work is necessary at the site,
<br /> ie,_?esent•and pr�,-vidt) or agency name.
<br /> !M- PORTAONT� THE INFORMATION PROVIDED ON THIS FORM IS INTENDED FOR GENERAL
<br /> )
<br /> IS NOT TO BE CONSTRUED AS REPRESENTING THE�FONSIELE PAR-'.' STAT S .-CALT PURP04ES ONLY AN-
<br /> er name, t person, and address of the party OFFICIAL POSITION OF ANY GMITEERNMENTALT AGENCY
<br /> telephon,, coi—,'a 1
<br /> responsible for ,1:e leak, Thc. responsible party would norm-ally be the tank
<br /> REMEDIAL ACTION
<br /> I Indicate which action have been used to cleanup or remediate the leak.
<br /> SITE LOCAT.C.N Descriptions of options folLow:
<br /> Enter infowrmation regarding the tank facility. At a miniw-um, you inAsL
<br /> provide the facility name full address. Cap Site - install horizontal impermeable layer to reduce rainfalL
<br /> infiltration.
<br /> TMFLENIIENTING AGENCIES Containment Barrier-- install vertical dike to block horizontal movement of
<br /> Enter names of the ',ocal. ag
<br /> tricj and Regional- Water Quality Control Board contaminant,
<br /> int,olved. I Excavate and Dispose - remove contaminated soil and dispose in approved
<br /> I
<br /> site.
<br /> SUBSTANCES TNt-Oh-VED Excavate and Treat - remove contaminated soil and treat (includes spreading
<br /> Enter the namc—di-id quantity lolt of the hazardous substance in1volved. Room or land farming).
<br /> is provided for' Information on)two substances if appropriate. If more than Remove Free Product - remove floating product from water table.
<br /> two substances leaked, list the two of most concern for cleanup. Pump and Treat Groundwater - generally employed to remove dissolved
<br /> contaminants.
<br /> DISCOVERY/ABATE-HENT Enhanced Biodegradation - use of auy available technology to promote
<br /> Provide irffo_-alat�on regarding
<br /> the disco-very and abatement of the leak. bacterial decomposition of contaminants.
<br /> Replace Supply - provide alternative water supply to affected parties.
<br /> Treatment at
<br /> SOURCE/CAUSE _Hookup - instaLl water treatment devices at each dwelling or
<br /> Indicate sou_ce(.j6) of lea"-. Check boxes) indicating cause of) leak. other place of use.
<br /> Vacuum Extract - use pumps or blowers to draw air through soil.
<br /> P-.
<br /> rA.SE IVY E Vent So"
<br /> - bore holes in soil to allow volatiLization of contaminants.
<br /> Indicate the c,a'5 e type category 1c_- this leak. Check one box only. Case No Artirom Reoired - incident is minor, requiring no remedial action.
<br /> type is based orf the moz if
<br /> sensitive resource affected. For example,
<br /> both soiL and prbund water 'have been affected, case type will be "Ground CGI-MENTS - VAe this space to elaborate on any aspects of the incident.
<br /> Water,, IndicatV "Drirding Water" only if one or more ;pa, or
<br /> domestic wator wells have actuaLly been affected. a A = Wat r SIGNATURE -Sign the form in the space provided.
<br /> designation doeslnot imply that the affected water cannot be, or is not.
<br /> used for drinking water, biat only that water wells have not yet been DISTRIBUTION
<br /> 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
<br /> investigation, and forward'tbe remaining copies intact to your local tank permitting agency
<br /> for distribution.
<br /> CURRENT STATUS- 0:-iginal - Lnpal Tank Permitting Agency
<br /> Indicate the category which best describes the current status of the case. 2. RegiouaD Water Quality Control Board
<br /> Check one box only, The response sllno*,uld be relative to thea e type-c 5 pe, For _A ..ocal ripalth Officer and County Roard of Supervisors or their designee to
<br /> if case type is,"Gro.und Water". then "Current Status- should refei _ receive' Proposition t,5 notifications.
<br /> example, � - : . '
<br /> to the status of the grcrr.A want, investigation or cleanup, as opposed to - 1 4 �fvnerlrasponsible party.
<br /> that of soil. Descriptions of options follow:
<br /> No Action Taken - No action has been taken by responsible party beyond
<br /> initial report "f I.-I—k
<br />
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