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I
<br /> INSTRUCTIONS
<br /> sMERG NCx
<br /> Leak Seim Cos2firmed.= Leak suspectba at site, but has not been confirmed,
<br /> Indicate whether emergency response personnel and equipment were iivolved Preliminar Site Assessment W-1—1— Submitted - workplan/proposal
<br /> at any time If "so, a Hazardous Material. incident Report should be filed _= requested of/submitted by responsibleparty roto determine whether ground
<br /> with the State Office of Emergency Services (0ES,) at 2800 Meadocvied Road, water has been, or will be, impacted as a:result of the release.
<br /> Sacramento, CA 95832, Copies of the<OES report corm may be obtained a PxeJ_iminar site-Assessmt t Tnde wax - implementation cf .workplan,
<br /> your local underground storage tare permitting agency. -Crdicate whether-,,-
<br /> Pollution Characterization - responsible party is in the process of -fully
<br /> tae QHS report has r sin filed as ofhe lots of this report_ defining,the ea ten.i of contamination in soil and ground water and assessing
<br /> impacts_ian surface and/or ground water,
<br /> LOCAL AGdCl L Il Y
<br /> Remediation Plan - remediation plan submitted evaluating long term
<br /> To avoid durlicate .,otification purs.rant to-sea'th and Safety code.�Secti'i7_ - - remediation options. Proposal and implementation sclZedule"for appropriate
<br /> d 25180,5; a> governm6nt employee should sign and date the-form in this,block, remedi-ition options also submitted,
<br /> A signature Dere does not mean that the leak has been determined to, pose a Cieancin I7nderwa° - implementation of remediation pian,
<br /> significant threat to human health 6j: safety, only that notification Post Clea nu t3oxxitorin.. in pr periodic ground water or other
<br /> procedures have been followed if required_ � monitoring at site, ,as necessary,. to veru} and/or evaluate effectiveness
<br /> of remedial activities.
<br /> . �C3R�P` Pi Case Closed - regional board and local agency in concurrence that no
<br /> Enter your nose, telephone number, and address, -Indicate which party you further work is necessary at the site.
<br /> represent .an, provide company or agency name.
<br /> IMPORTANT; THE INFORMATION PROVIDED O BTS FORM, IS INTENDED FOR GENERAL
<br /> s RESF'ONS t:P; PPORTY STATISTICAL AL PURPOSES OBEY
<br /> 'AND SS NOT 13 BE CONSTRUED LYE As REPRESENTING RS 2iTSNC `z.I
<br /> Enter na.a _x3 acre somber, contact person, and address of the Marty OPPZCSt1L POSITION .OP ANY COdli:aNN11 NTAL AGE
<br />;., respows ble for the leak, The responsible party would normally Be the t-an
<br /> osvzzer. IcEt2,DIAI ACTION
<br /> Indicate which action have been used to c eancp or remediate the leak.
<br /> Desc
<br /> SITE LOCATION
<br />� �.�,�„riptioxz�, of optz.axsr��fzalloiu;
<br /> Enter information regarding the tank facility. At a minimum, you crus;
<br /> provide tb-;- facility name and full address. - gate._ install horizontal i.npormeable layer to reduce rainfall
<br /> infiltration,
<br /> TP E%EtIT." v'ES Containment Harrier install vertical dike to b ocl aorizanta nForr:nF <at of
<br /> x Enter i zetas of the local.,agency and"Regional: Water Quality gontrol Board contaminant,
<br />� involved, Excavate and Dispose remove cet��mxi�,red sal on. in approved
<br /> r site,
<br /> SUBSTANCES zri 3 t D Excavate asci Treat - remove cantam—mated sol; and trrwat, cS a, Spreading
<br /> Enter the Haire and quantity lost of the hazardous substance involve n=om or land farming),
<br /> is provided for information on tura substances if appropriate, if =nor_ than Remove Free Product, - rerjov float-ng prod.ct. from _cater table,
<br /> two substances looked, list the two of most-concern for cle sp, P-a.„ro and Treat Grounds -- generally em_ aged to remove dissolved
<br /> contaminants.
<br /> DI SCOVLk&F I r i.vx unt anceT Pivae _ ` use of a .y ava a abi.e tec_.n_l ogy to promote
<br /> Providenfo m.ata.esia regarding the disco<°ery`ard abatement of the IaSalk, bacterial decomposition of contaminants,
<br /> B±,R- cr Provide alternative water supply to a
<br /> ffected parties,ies.
<br /> ISOTr es_ mate treatment devices a each aW . ien
<br /> or
<br /> C.d=cat_ sourcels) of leak, Check iox?es) indicating cause of leap. outer place
<br /> fUs
<br /> Vacuum Extract - use p nps or bhscrs to dray air tbrough soil,,
<br /> :>E TYPE Went Sora - bare holes in ,sail to allow volatilization of ontxniraants.
<br /> Indicate _ne case type 'category for this leak, Check one box only. Casedo Action e gfired - incident is minor, requiring no remedial_ action.
<br /> { type is Lased on the most sensitive resource affected. For example, if
<br /> bath soil and ground water have been affected, case type will be "G.rourd COMMENTS - Use this space to elaborate or, any aspects of the incident,
<br /> -
<br /> Water", Indicate "Drinking Suter" only if Zone or more municipal or
<br /> domestic water wells have actually been affected. A "Ground Water SIGNATURE - Signa the form in the space provided,
<br /> designation foes not imply that the affected water cannot be, or is no°t.
<br /> used for drinking water,-but only that water wells have not yet been DISTRIBUTION
<br /> affected< It is understood that case type may 9hange upon farther If the form is completed by the tanto owner or his agent, retain the last copy
<br /> rvestagatior. and forward the remaining copies intact to your local tank permitting sgency
<br /> for distribution.
<br /> CURRENT STATUS
<br /> :a l< Original - Local Tank Permitting Agency
<br /> Indicate the category which best describes the current status of the case, ' 2, state Water Resources Control Board, Division of Clean mater Programs,
<br /> Check one box only, The response ,should be relative to the-e`ase type. For Underground Storage Tank Program, PIC, Box 944212, Sacramento, OA 94244-
<br /> example, if case type is "Ground nater", then "Current Status" should refer 2120
<br /> to Lhe status of the ground water investigation or cl.earap, as opposed to .3. Regional Water,Quality Control Board
<br /> that of soil, Descriptions of options follow: � 4, Local Health Officer and County Board of Supervisors or their designee to
<br /> v _ receive Proposition 65 notifications,
<br /> No Action Taken - No action 'ha's been tamer by responsible party beyondI erlrespo sib7e party.
<br /> i:_.ti<„_ i of leak.
<br />
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