COMPLIANCE INFO_2003-2008 - Laserfiche WebLink

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EMERGENCY Leak Bein Confirme 7 Leak suspected at aite,'but hes not been confirmed. Indicate whether emergency response personnel and equipment were involved Preliminar7 Site Assessment Work len Submitted - workplan/proposal at any time. If so, a hazardous Material Incident Report should be filed requested of/submitted by responsible party to determine whether ground with the Stats Office of Emergency Services (OES) at 2800 Meadowiew Road, water has been, or will be, impacted as a result of the release. Sacramento, CA 95832. Copies of the OES report form may be obtained at Pxeliminar Site Assessznent'Underwa - implementation of workplan, your local underground storage tank permitting agency. Indicate whether Pollution Characterisation A responsible party is in the process of fully the OES report has been 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 Remediation Plan -"remediation plan submitted evaluating long term To avoid duplicate notification pursuant to health and Safety code Section remediation options. Proposal and implementation schedule for appropriate 25180.5, a government employee should sign and date the form in this block. remediation options also submitted, A signature here does not mean that the leak has been determined to pose a Cleanu nderwa implementation of remediation plan, significant threat toto human health or safety, only that notification Post cleanu [anitarin in Pro sass - 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 Closed - regional board and local agency in concurrence haat no Enter your name, telephone n rtta number, and address, Indicate which party you fuer work is necessary at the'site. represent and provide company or agency name. IMPORTANT: THE INFORMATION PROVIDED-ON THIS FORM IS INTENDED FOR GENERAL RESPONSIBLE PARTY STATISTICAL PURPOSES ONLY AND IS NOT TO BE CONSTRUED PRESENTING THE Enter name, telephone number, contact person, and address of the party OFFICIAL POSITION OF ANY GOVERNMENTAL AGENCY responsible for the leak, The responsible pa ty- uld normally be the tank owner. REMEDIAL ACTION Indicate which action have been used to cleanup'Yor 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. 9,1P Site - install. horizontal Impermeable layer to reduce rainfall infiltration. IMPLEMENLING AGENCIES Containment Barrier - install vertical diti to block horizontal movement of Enter names of the local agency and Regional Water Quality Control Board ontaminant. involved. Excavate and Dir sae - remove contaminated soil and:dispose in approved site. , SUBSTANCES INVOLVED Excavate and Treat - remove contaminated sail and treat (includes spreading Enter the name and quantity lost of the hazardous substance involved. Room or land Farming), ' is provided for information on two substances if appropriate. If more than Remove Free Produ t - remove floating product from at�r teb1e< two substances leaked, list the two of most concern for cleanup. aand Treat Groundwater - generally employed to remove dissolved contaminants. DISCCi �Il AT NT Enhanced Biode radatian - use of any available technology to promote Provide information regarding the discovery and abatement of the leak, bacterial decomposition of contaminants. ' Replace Suxazall - provide alta ati.ve water supply to affected parties.' S9URCE CATJSE Treatment at Pucka - install water treatment devices at each dwelling or Indicate source(s) of leak. Check box(es) indicating cause of leak. other place of use. Vacuum Extract - use pumps or blowers to draw air through .soil. CASE TYPE Vent Soil - bore holes in soil to allow volatilization of contaminants.' Indicate the case type category for this leak. Check one box only. Case No Actio Re irad - incident-is minor, requiring no remedial action. type is based on the most sensitive resource affected. Por example, if both soil and ground water have been affected, case type will be "Ground COMtENTS - User-this space to elaborate on any,aspects of the incident. Water". Indicate "Drinking Water" only if one or mord municipal or domestic water wells have actually been affected. A "Ground Water" SIGNATURE - Sign the farm 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 DISTRIBUTION affected. It is understood that case type may change upon further I£ the form is completed by the t owner or tail agent® retain the Iasi copy investigation. and forward the remaining copies intact to your local tank permitting agency for distribution. CURRENT STATUS 1, Original - Local Tank Permitting Agency Indicate the category which best describes the current status of the case. 2. State mater Resources Control Board Division of Clean Water Programs, Check one box only. The response should be relative to the case type. For Underground Storage Tank Program, P.O. Box 944212, Sacramen,1% CA 94244- example, if case type is "Ground mater", then "Current Status" should refer'..... 2120 to the status of the ground water investigation or cleanup, as opposed to 3. Regional Water Quality Control: Board that of soil. Descriptions of options follow: 4. Local Health Officer Masi County Board of Supervisors or, their desigaee to receive Proposition 65 notifications. No Action Taken No action has been takers by responsible party beyond 5. Owner/responsible party, initilal report of Leak.