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INSTRUCTIONS
<br /> :. EMERGENCY
<br />•' Indicate whether emergency response personnel and equipment were involved workplan/proposal
<br /> at any time. If so, a Hazardous,Material Incident Report should be filed requested of/submitted by responsible party to determine whether ground
<br /> with the State Office of Emergency Services'(OES) at 2800 Meadowview Road, water has been, or will be, impacted as a result of the release.
<br /> Sacramento, Ca 95532. Copies of the OES report formmay be obtained at PreliminarySite Assessment Underwa implementation of workplan.
<br /> your local underground storage tank permitting agency. Indicate whether Pollution Characterization - responsible party is in the process of fully
<br /> the`"OES report hasbeen filed as of the date of this report, defining the extent of contamination in soil and ground water and assessing
<br /> impacts on surface and/or ground water.
<br /> LOCAL AGENCY ONLY- Remediation Plan - remediation plan submitted evaluating long term
<br /> To avoid duplicate notification pursuant to.Health and Safety code Section remediation options. Proposal and implementation schedule for appropriate
<br /> 25180.7,, a designated government employee should sign and date the form in remediation options also submitted.
<br />" this block. A signature here does not mean that the leek has been Cleanup Underway - implementation of remediation plan.
<br /> determined to pose a significant threat to human health or safety, only Post CleanuR_ onitoring in Progress - periodic ground water or other
<br /> that notification procedures have been followed if required. monitoring at site, as necessary, to verify and/or evaluate effectiveness
<br /> of remedial activities,
<br />�'• RTED Y Case Closed - regional board and local agency in concurrence that nes
<br /> Enter your',name, telephone number, and address. Indicate which party you further Mork is necessary at the site.
<br /> represent and provide company or agency name.
<br /> IMPORTANT: THE INFGRMATION PROVIDED ON THIS FORM IS INTENDED FOR GENERAL
<br /> 1WSPONSIBLE.P TY STATISTICAL PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REPRESENTING THE
<br /> Enter-name, telephone number, contact person, and address of the party OFFICIAL POSITION OF ANY GOVERNMENTAL AGENCY
<br /> responsible for the leak, The responsible party would normally be the tank
<br /> owner. R2ADIAL ACTION
<br /> Indicate which action have been used to cleanup or remediate the leak.
<br /> SITE LOCATION Descriptions of options follow:
<br /> "i Enter information regarding the tame facility. At` a minimum, you must
<br /> provide the facility name and full address. Cap Site - install horizontal impermeable layer to reduce rainfall
<br /> infiltration.
<br /> IMPLEMENTING AGENCIES Containment Barrier - install vertical dike to,block horizontal movement of
<br /> Enter names of the local agency,and Regional Water Quality Control Board contaminant.
<br /> involved. Excavate and Dispose - remove contaminated soil and dispose in approved
<br /> site.
<br /> SUBSTANCES INVOLVED Excavate and Treat - remove contaminated soil and treat (includes spreading
<br /> Enter the name and quantity lost of the hazardous substance involved. 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 />'n
<br /> DISCOVERY/ABATEMENT Enhanced Biodegradation - use of any available technology to promote
<br /> Provide information regarding, the discovery and abatement of the leak, bacterial decomposition of contaminants.
<br /> Reulace Supply - provide alternative water supply to affected parties.
<br /> SO CEJCAUSE Treatment at Hookup - install water treatment devices at each dwelling or
<br /> ,;Indicate source(s) of leak. Check box(es) indicating cause of leaf. other place of use.
<br /> Vacuum Extract - use pumps or blowers to draw air through soil.
<br /> ASE TYPE tent Soil - bore holes in soil to allow volatilization of contaminants.
<br /> Indicate the case type category for this leak. 'Check one box only. Case No Action RequLred - incident is minor, requiring no remedial action.
<br /> type is based on the most sensitive resource affected. For example, if
<br /> both soil and ground water have been affected, case type will be "Ground 2014ENTS'- Use this space to.elaborate on any aspects of the incident.
<br /> Water". Indicate "Drinking Water" only if one or more municipal or
<br /> domestic water wells have actually been affected. A "Ground Water" SIGNATURE_ Sign the form. in the space provided.
<br /> designation does not imply that the affected water cannot be, or is not,
<br /> used for drinking water, but 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 fo and the remaining copies:intact, to your local tank,pormitting agency
<br /> for dtstribati'
<br /> CURRENT STATUS 1. ^Original 4.Looa1 I' .,Peru i.ttift Agency%,.
<br /> Indicate,the category which best describes'•the'current status of the case. 2. State Water Reso,qP 'iS,Contr�61 'board, Division of,Loana: d,Grants,
<br /> Check one box only. a response should be relative to the case type. For Underground Storage-Taxzlc program, P.O. Box 94421Z, ''Sacr ento;'' CA•94244`
<br /> example, if case type is "Ground Water"', then "Current Status" should refer 2120
<br /> to the status of the ground water investigation or cleanup, as opposed to 3. Regional Water Quality Control Board
<br /> that of soil. Descriptions of options follow: 4. County Board of Supervisors or designee to receive Proposition 65
<br /> notifications.
<br /> No Action Taken - No action has been taken by responsible party beyond: 5. Owner/responsible party.
<br /> initial report of leak.
<br /> Leak Being Confirmed - Leak,suspected at site, but has not been
<br /> confirmed.
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