COMPLIANCE INFO_1984-1994 - Laserfiche WebLink

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INSTRUCTIONS EMERGENCY CURRENT STATUS Indicate whether emergency response"personnel and equipment were involved at n icate t e category which best describes the current status of the case. '~ any time. If so,- a Hazardous Material Incident Report should be filed with Check one box.bnly. The:response should be relative to the case type. :For the State Office of Emergency Services (DES) at2800Meadowview Road, example, if case type is "Ground Water", then "Current Status" should refer to Sacramento, CA ~95832. Copies of the DES report form may„be obtained at,your ” the status of the ground water investigation or cleanup, as opposed to that of sojl. Local underground storage tank permitting agency. Indicate whether the DES ` report has been filed as of the date of this .report. IMPORTANT: THE INFORMATION PROVIDED ON THIS FORM IS INTENDED FOR GENERAL ;... LOCAL AGENCY ONLY. STATISTICAL PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REPRESENTING THE To avoid;duplicate notification'pursuant to Health and Safety Code Section OFFICIAL POSITION OF ANY GOVERNMENTAL AGENCY 25180,7, a designated government employee should sign and date the form in this block. A signature here does not mean that the leak has been determined REMEDIAL ACTION to pose a significant threat to uman health ar afety, only that,notification 'Indicate which actions have been used to cleanup or remediate the leak. AdNIN procedures have been followed if required. Descriptions of options follow: REPORTED BY Ca Site - install horizontal impermeable layer to reduce rainfall rater your name, telephone number, and address. Indicate which party you n 7 an,. represent and provide company or agency name. Containmennment Barrier- install vertical dike to block horizontal movement of contaminant. " RESPDNSIILE PARTY Excavate and Dispose - remove contaminated soil and dispose in,approved nter`name, telephone number, contact person, and address of the,party site. 3 Excavate and Treat - remove contaminated soil and treat (includes responsible for the leak. The responsible party would normally be the tank ` owner, spreading or an farming). r' Remove Free Product - remove floating product from water SITE LOCATION to e. Enter�ormation regarding the tank facility and surrounding area. At a Pump and Treat Groundwater - generally employed to remove dissolved minimum, you must provide the facility' name and full laddress. contaminants-. Enhanced Biodegradation - use of any available technology to promote IMPLEMENTING AGENCIES bacteri alTcecomposition of contaminants. Enter names o 2 t ocal agency and Regional Water Quality Control Board Rep ace Supply - provide alternative water supply to affected involved. parties. TreajTtnt at Hooku - install water,treatment devices at each dwelling or " SUBSTANCES INVOLVED ofr—Fer PTaceusi No Action Re aired - incident is minor, requiring no Enter the name and quantity lost of the hazardous substance involved. Room is remedial action. provided for information on two'.substances if appropriate. If more than two "z substances leaked, list the two of most concern for cleanup. COMMENTS - Use this space to elaborate on any aspects of the incident. DISCOVERY/ABATEMENT SIGNATURE - Sign'the form in the space provided. Provide 'information regarding the discovery and abatement of the leak. -0-1 BU ION mow" If the"form is completed by the tank owner or his agent, retain the last copy SOURCE/CAUSE Indicate'source(s) of leak. Provide details on tank age; capacity and and forward the remaining copies in tact to your local tank permitting agency T material if known. Check box(es) indicating cause of leak. for distribution. ' 1. Original —Local Tank Permitting Agency ( CASE TYPE 2. State Water Resources Control Board, Division of Water Quality, n icate the case type category for this teak. Check one box only. Case typeUnderground Tank Program, P 0. Box 100, Sacramento, CA 95801. 3. Re Tonal Water Quality Control Board ( is based on the most sensitive'resource affected. For example,` if both soil g a. 4. County,Board of Supervisors or designee to receive Proposition 65 and ground water have been affected, case type will be "Ground Water V Indicate "Drinking Water" only if one or more municipal or domestic water notifications. wells have actually been affected. A "Ground Water' designation does not 5. Owner/responsible party. imply that the affected water cannot be, or is not, used for drinking water,, but only that water wells have not yet been affected. It is understood that case type may change upon further investigation.