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EMERGENCY leak Be,- ro Pirmed - Leak suspected at site, but has not been confirmed.
<br /> Sndicate whether emergency response personnel and equipment were involved Paelimina Site Assessment Work len Submitted - wdrkplan/pzoposal
<br /> at any time. If so, a Hazardous Material Incident Report should be filed. ra ested of/submitted by responsible party`to determine whether ground
<br /> with the State Office of Emergency Services (OES) at 2840 Meadowview Road,. water has been, or will be, impacted as a result of the release.
<br /> Sacramento, CA 95832. Copies of the OES report form may be obtained at Preli In Site Assessment n
<br /> erwa - Implementation ofworkplan.
<br /> your local underground storage L pexasitt£ng agency, Indicate whether Pollution Ctaaracterization es oasibla, party is in the process of fully
<br /> the OES report teas been filed as of the data of Ltais re zt, finthxtentofctn i8i in soil and ground water d assessing
<br /> iceapadts on surface and/or grou water.
<br /> LOCAL AGENCY C)IdLY Remediation Plan r .diatio s itted evaluating long term
<br /> To avoid duplicate notification pursuant to Health.and Safety cede Section remediation options. Pzoposal, nd;i lsananLation sotaedule for appropriate
<br /> 25180.5, a government employee should sign and date the forma initis block, remediation optioz)s also submitted.
<br /> A signature here does not mean that the leak has been determined to se a Cleanu Llnderwa - $mplementation of remediation plan.
<br /> significant threat to Ku-man health or safety, only that notification Post Cleanu Monitoring in Progress - periodic ground Qatar or other
<br /> procedures have been followed if required. monitoring at site, as necessary, to verify and/or evaluate effectiveness
<br /> of remedial activities.
<br /> REPORTED BY Case Closed - regional board and local agency in concurrence that no
<br /> ! Enter your name, telephone number, and address. Indicate which party you further work is necessary at the site.
<br /> represent and provide company or agency name.
<br /> /RESPONSIBLE PARTY IMPORTANT: THE INFORMATION PROVIDED ON'THIS FORM
<br /> IS INTENDED FOR GE ,
<br /> STATISTICALPURPOSES ONLY AND IS NOT TO,BE CONSTRUED AS SENTING THE
<br /> enters e elephe l number, contact parson, and address of the party OFFICIAL, POSITION OF, Y GC NTAL AGENCY
<br /> re bl � oz the leak. The responsible party would no ally,be the t
<br /> owner.' ' REMEDIAL ACTION
<br /> SITE LOCATION Indicate,"Which action have been ue� to cleanup or r6mediate the leak.
<br /> Enter information regarding the tank facility. At a minimum, you must esczipt ons of options follow:
<br /> provide the facility name grad full address. Ca Site install horizontal a "!able Layer to reduce rainfall
<br /> infi trmtion. i;>
<br /> IMPL TiTING AGENCIES Con ai ant Barrier install ;nidal dike to block horizontal movement of
<br /> Enter n es of the local agency and Regional Water Quality Control Board contaminant.
<br /> involved. Exo ate and Dispose - remove conta'in'
<br /> ated aoil' xzd dispose in e
<br /> S ST CES I Ol D site.
<br /> Po approved
<br /> Excavate and Treat - remove contaminated soil and treat (includes spreading
<br /> Neter the
<br /> n a and entity lost of the hazardous substance involved. Room or land fa ing). .
<br /> is prodded 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. Fume end Treat Groundwater - enesally employed to ramoove dissolved
<br /> DSS Y! AT NT cont inax{Ls,
<br /> ntaancad ode zadaticn -
<br /> Provide information regarding the discovery and abatement of t&s azse any available technology to promote
<br /> leak, bacterial deco osititsn of cone iia ts.
<br /> Ra lace Su , 1 = provide alte ytive water supply to affected parties.
<br /> Q CE AUE TreataaaenL aL £lookup - install '"ter treatment devices at each dwelling or
<br /> Ind tate source s) of leak. Check box(es) indicating cause of .leak. otkser place ref use.
<br /> i_ vacuum Extract - use pumps or Mowers to draw air through soil. AMh
<br /> ndicatPN Vent'Soil-- bare holes in eoi3 'to allow volatilization of contaminants.y �?
<br /> Sndicate th se type category for this leak. Check one box oilya Case No Ac an"Z3e reed - sin 8ni Minor, volatilig no medial action.
<br /> type is based-.on the most sensitive resource affected, For ®xample, �f
<br /> both. of and ground water have been affected, case type will be "Ground NTS' - Use'this space to elaborate on any aspects of the incident,
<br /> €dater". Indic at `°°Dri ing Water"'only if one or more municipal or
<br /> domestic water wells have actually been affected:: A°"Ground Water" SIG%lAT Sign the form in the space provided.
<br /> k designation does not imply that thea affected water o of be, or is not,'
<br /> used for drinking water, but only that water wells have not yet been uSSTRIB()TIC}N
<br /> . affected, It is understood that case type may change upon further
<br /> investigation, Y the furan is completed by the tank owner or his agent, retain the last copy
<br /> and for and the remaining copies intact to your local 't pe itting agency
<br /> for distribution. y
<br /> 2-- 1,'
<br /> 1,` Original - Local Tank Permitting Agency
<br /> Indicate the category which best describes the current status of the case. 2; State dater Resources Control Beard, Division of Clean Water Programs,
<br /> Check one box only. The response should be relative to the cask"type, ;For Und�rg`round Storage Tank Progr '°;, P.O. Box 944212, Sacramento, CA 44244-
<br /> example, if case type is "Ground Mater", then "Current Status" 0ould refer 2120
<br /> to the status of the ground water investigationor cleanup, as opposed to 3t_ Regional Water Quality'Contrdl, Board
<br /> that of soil. Descriptions of options follows 4.. Local,Health officer and County Board of Supervisors or their designee to
<br /> receive Proposition 65.notifications,
<br /> No Action Taken - No action has been taken by responsible party beyond 5. Owner4responsible partyr.
<br /> initial report of leak.
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