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TNST CTIONS
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<br /> EMERGENCY Leak suspected at site, but has not been confirmed.
<br /> Yhoicate whether emergency response personne7 and equipment were involved Preliminer Site W—J� lan Submitted - workpian/proposal '
<br /> at any time, If so, a Hazardous Material Incident Report should be filed requested of/submitted by respona-Tb7l.e party to determine whether ground
<br /> with the State Office of Emergency Services (OES) at 2800 Meadowv`ew Road, water has been, or will be, impacted as a result of t-�
<br /> Sacramento, CA 95832. Copies of the OES report form may be obtained at --e release,
<br /> EreLiminar_y Site Assessment im.plementation of workplan,
<br /> your local underground storage tank permitting agency, indicate whethe- EP2allutjion Character
<br /> LiLzation respors''ble party in the crocess of fully
<br /> the OES report has 31-�en filed as of the date of this report. defining the extent of contamination soil, wnd ground outer and assessing
<br /> impacts on surface and/or ground water,
<br /> NLY
<br /> LOCAL AGENCY 0' Remedatan Plan - remediation p an sulmo4tted evaluating long t r
<br /> � I-�11 -'� a m
<br /> To notification pursuant to Health and Safety code Se�t-Jon remediation options, Proposal, and imp� �—
<br /> ....ern.entat.Jon schedule far appropriate
<br /> 25180,5, a government employee should sign and date the form Jn this bdools- remediation options a'-so submitted,
<br /> A signature here does not mean that the leak has been determi'ej -
<br /> r - to pose a 9.1�eani-u) U�nderwa� - implementation of 7remedliation plan.
<br /> significarit threat to human health or safety, only that notificavil-111 Pcriodic Aronnd water or other
<br /> procedures have been followed if required, monitoring at site, as necessary, to ver'f:,,, Fn,.I/,)r evaluate effectiveness
<br /> of remedial activities,
<br /> REPORTED BY
<br /> �ase Closed - regional board and local-11 atency in cQncuxrence that no
<br /> Stn'at telephone number, and address, Indicate Which party you further work is necessary at the slite,
<br /> d prova.da company or agency name,
<br /> re
<br /> 4 ep so
<br /> I
<br /> a
<br /> IMEIORTANT� THE INFORMATION PROVIDED CA THIS FORM !S INTENDED FOR GENERAL
<br /> LE
<br /> _-IPONSILI��r PAR11 "ISITCAL PURPOSES ONLY AND IS NO'i' TO BE'CCNI S TRUED AS REPRESENTING THE
<br /> IA-
<br /> ALI
<br /> Enter name, te.Lephone number, contact person, and address of the patty 0-FI'CT,&L D N OF A14Y GOVERNMEFNTAL AGENCY
<br /> POSITIO
<br /> responsib.1-a far the ',,-ask. The responsible party would normally be the t an-,'s-'
<br /> ro
<br /> owner,
<br /> 2�
<br /> Indicate which action have been ure-,d, to ciennup or rccnediate the IeLlk,
<br /> SITE LOCATION EeEcriptions of" upt"'Ons fellow:
<br /> Enter information regarding the tank facility, At a minimum, you muat
<br /> provide the facilitY name and full address, install horizontal. impermeable, to rudors rainfall
<br /> infiltration,
<br /> -NCIES
<br /> L1=----1 Contaipment Barrier install d-il-le tic� block movement of
<br /> V IMPLEMENTING AS...
<br /> cal agency and Regional Water Quality Contra! Board 17)--1,
<br /> Enter names of the 10
<br /> involved,
<br /> Exo-vatl�eft sand D- reesn,,,o, soa,' and dJsi��ose in approved
<br /> alTe
<br /> SUBSTANCES iNVOLVED Excava a and Treat - remove I and treat (Inc`udes spreading
<br /> N lost of the hazardou3 substance in-aolved� Ro,,,x, L�1—
<br /> T��,,erthW or -land farnAng),
<br /> is provided for information on two substances if a-j I mo a r a Remove F-ee P-oduct - remove f],,oat
<br /> propriate, I n, th, n
<br /> two substances leaked, 1. - I, prod""t froT" Water table,
<br /> �Ist the two of most concern for cleanup, a P er a ssol a
<br /> Le:q�and t_Gro-und�� to re-�ove di -1v d
<br /> conftwnnonants,
<br /> DISCOVERVABATENIENT -Enhanc d Biodft_wrau-tion, - u1se Of auny avai-able teclanclogy to prociote
<br /> Provide informat.",on regarding the discovery and abatement of the leak, 1-,,acter.'al decompositiian of contacninpnts,
<br /> e F, --Sup, lls� - provide alternativp wate-c sa�o -1-y to affected parties
<br /> AdIkSO-URCE/CAUSE - q— -
<br /> Treatmen. at. - inst-a.'-' w-,te- �-ea,,mLnt 6ev"cos at each dwelling or
<br /> 'fIn of Leak, Check box"es) indicating cause of leak� other Piece of use,
<br /> CASE TYPE Extra - use Pumps or blowers to dzew air through sail�
<br /> n t,- z;,2 i-1 bore holes in sall tQ allow v�)Iat-,i"Lization of contaminants,
<br /> Indicate the case tYpo category for this leak. Check one box Caae No AcrTo7n Reo-uired - incidert is mJnor, ra,'pir4ng no remedial action,
<br /> �t pe is based or- the most sensitive resource affected, For examp,lle� if 0,
<br /> y
<br /> oth sail and ground water have been affected, case type will be "GrouK'd Use this space to elabol-ate on, any acp 11 Tic ident,
<br /> COkVIENTS � e
<br /> Water", indicate "Drinking Water" only if one or more municipal or �rts of t e i
<br /> domestic water wells have actually been affected, A "Ground Water" SIGNATURE SiAn the form in the space provided.
<br /> designation does not imply that the affected water cannot be, or is noL
<br /> used for drinking water, but only that water wells have not yet been DTS—IBU-!ON
<br /> affected. It is understood that case type may change upon further I' the form is com-pleted by the tank owlner or his agent, retain the last cop
<br /> investigation, an d forward the remaining copies intact to You! local tank permitting agency y
<br /> for distribution,
<br /> CURRENT STATUS I Original - Local Tank Permitting Agency
<br /> Indicate the category which best describes the current status of the case, St-a,te� Wa�ter Resources Control Board, Divj,sJon of Clean Water Programs,
<br /> Check one box only. The response should be -relative to the case type, For Underground Storage Tank Program, P,O� Box'94421.2. Sacramento. CA 94244-
<br /> example, if case type is "Ground Water`, then "Current Status" should refer 21-20
<br /> to the status of the ground water investigation or cleanup, as opposea, to 3, Regional Water Quality Central Board
<br /> that of sail, Descriptions of options .�ollow: 4. Local Health Of-ricer and County Doard of Superviscre or their designee to
<br /> rec=J ve Proposition -65 notifications,
<br /> No ActioLl Taken - No action has been taken by responsible party beyond, Cwno �responsible party.
<br /> i rii,t i a 1 of leak,
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