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INSTRUCTIONS
<br /> EtRGEC1 Leak Being Confi.xmed - Leak suspected at site, but has not been confirmed.
<br /> 'Indicate whether emergency response persoa.neL and esusentWere evolved Ixeliminar Site Assessment Workplan Submitted - workplan/proposal
<br /> at any tit*, If so, a `Hazardous Materia 'Incident,Report should be file requested of/submitted by;responsible party to determine whether ground
<br /> with the..ltate Office of Lmergency Sery-c s 'CES) at 2800 Meadowview Road,' water has been, or will. e, impacted as a result of the release.
<br /> :Sacramento; CA 95832. Copies of the OES report form may bs,obtained at Preliminary Site Assessment Underway - 4mplementation o workplan:
<br /> your local underground storage tares permitts.ng",agency " Za irate whether": Pollution Cnaraterizat.ion . responsible party is in the pro ess of fully
<br /> the OES report has been filed as of the date of this r,` ort: defining the extent of contamination inisosl and ground water and assessing
<br /> impacts, on: surface and/or groundwater.
<br /> 'LOCAL AGENCY OL+iY Remediation Flan remediation plan submitted evaluating long term
<br /> To,avoid duplicate notif),cation:pursuant to Health and Safety code Section remediation options. Proposal and implementation schedule for app.ropriate
<br /> 25i80.5, a government ,ployee. should sign and date the form: in this block. remediation options also submitted.
<br /> A signature here does not mean that the leak has been deteiw nod to pose a CleanuFa Underway - implementation of remediation plan.
<br /> significant threat to human wealth or safety, only that notification periodic ground water or other
<br /> procedures have been followed if recpjired.` monitoring at site, as necessary, to verify and/or evaluate effectiveness
<br /> of remedial activities.
<br /> REPORTED BY Case Closed-- regional board and local:agezicy in concurrence that':'no' .
<br /> Enter your name, telephone number, and address. Indicate vahacn Tarty yova further work is necessary at the:s`"ite.
<br /> represent and protide company or agency name, '
<br /> IMPORTANT: THE'INFORMATION PROVIDED ON THIS FORM IS INTENDED FOR GENERAL
<br /> RESPONSIBLE PARTY STATISTICAL PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REPRESENTING T'HE °t
<br /> Enter name, telephone number, contact person, and address of the party OFFICIAL POSITION OF GOVERNMENTAL,AGENCY
<br /> responsible for the leak. The responsible party would normally be the tank
<br /> owner.
<br /> ERgDIAL
<br /> Indicate which action have been used to cleanup or remediate the Teair,
<br /> SITE LOCATION Descriptions of options fallow;
<br /> Enter information regarding the tank facility. At a minimum, you must
<br /> provide the facility name and full address. Can Site - install horizontal impermeable layer to reduce rainfall
<br /> infiltration.
<br /> IMPL21ENTING 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 Apreading
<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 /> DISCOVERXZAgATEMENT Enhanced Biodegradation. - use of any available technology to promote
<br /> Provide information regarding the discovery and abaterwient of the leak, bacterial decomposition of contaminants.
<br /> Replace SupFlY - provide alternative water supply to affected parties.
<br /> SOURCEfCAt3SE Treatment at HookuR -.install water treatment devices at each dwelling or
<br /> Indicate sour'ce(s) of leak. Check box(es)" indicating cause of leak. other place of used
<br /> " Vacuum Extract - use pumps or blowers to draw air through soil.
<br /> CASE TYPE Vent 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 Rtgm red - incident is minor,,requiring no-remedial action,
<br /> type is based�on the most sensitive resource affected.- For ekample, if
<br /> bothsoil and-ground water have been affected, case type will be "Ground C NTS -"Use this space to elaborate on any aspects of the incident.
<br /> Water°t.;` Indicate "Drinking Water" only if one or more municipal or
<br /> domestic water wells have actually been affected. A "Ground Water" ' SIGNATURE,- Signa the form in the space provided,
<br /> deignation does not imply that the affected water cannot-Fie, or is ':not,
<br /> use'a for drinking water, but only that water wells have not yet been DISTRIBUTION
<br /> affected. 3t 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 forward the remaining copies intact to your local tank permitting agency
<br /> for distribution.
<br /> Cf NT STA1"US 1. Original -.Local Tank Permitting Agency
<br /> Indicate the category which best'describ ' tire current status of the case. ' 2. State Water:Resouroes Control Board, Division of Clean Water Programs,
<br /> Check one box only. The response should be relative to the case type. for Underground;Storag Tank. Program, P.O. Box 944212, Sacramento', CA 94244-
<br /> example, if case type is'-Ground Water'", then "Current Statzs" should refer 2120
<br /> to the status of the ground water investigation or cleanup. as opposed to 3 Regional `slater Quality Control Board
<br /> that of soil.. Descriptions of options fo .
<br /> p llcc, 4. Local Health Officer and County Board of Supervisors or theix':desigraea to
<br /> receive Proposition 65 notifications,
<br /> ho .Action Taken - No action has been takon lay,responsible party beyond 5 Owner/responsible',party.
<br /> initial' report, of leak.
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