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<br /> INS T ONS
<br /> EIRIE°TCY Leak Beins�Cont rmed° Leak suspected at site, but has not been confirmed.
<br /> Indicate whether emergency response personnel and eTu? n, were involved Preliminary Site Assessment torkplan Submitted'-'workplan/proposal
<br /> at any time, If so, a Hazardo=us Materia' Incident. Report should be filed requested csfjsubmi�ted by respozBible party to detercai ne whether ground
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<br /> vi the Stave Office of Emergency Services (,^.ES) .at :eadowview Road; water has beeam, or ra?1 Sae,"impacted as-a result of tete release,
<br /> Sacramento—CA 95832. Copies of the QES report form may be obtained at Prelisinar� Site Assessment Underway - i€stplemaittazion of workplan.
<br /> your Local underground storage tank permitting agency. Indicate whether PcSiLu ietz Characterization - responsib e party is in the „rocess sat fully
<br /> ttae`OES report has been filed as of the date of this report, destining tte."extent of �{3Zazaminat on in soil and ground gatexand assessing
<br /> impacts on surface'and/or ground water.
<br /> LOCAL AGENCY t3tYLY Remediation Plan r4mediatioi plans submitted evaluating l to
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<br /> Ta„avoid duplicate notification pursuant to Beal and Safety code Section remediation 'dptlons. Proposal and implementation schedule for appropriate
<br /> 251$0.5, a government employee should signand date the form ,.n this block. remadiation options also'submitted.
<br /> A -signature here does not mean that the leak has been determined to pose a Cleanup Underway - implementation of remediation plan.
<br /> significant threat to Human=health or safety, only that notification Post'Cleanu onitor''in iu °ro rens - periodic :ground water or canner
<br /> procedures have been followed if required, monitoring at site, as necessaryq "to verify and/or evaluate effectiveness
<br /> of remedial activities.
<br /> RE€€IRT D BY C e'Closed -;regiopal board and local agency in concurrence that no
<br /> Eziter Your name, telephona'number, and address. Indicate w}tich party you further work is neress , at the'site,
<br /> represent and provide company or agency name.
<br /> IMPORTANT: THE INFORMATION PROVIDED ON THIS FORM IS INTENDED FOR'GENERAL
<br /> RESPONSIBLE PARTY STATIB ICAL PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REPRESENTING THE
<br /> Enter name, "telephone number, contact person, and address of the party OFFICI POSITION OF GOVERNMENTAL AGENCY
<br /> responsible for the leak. The responsible party would normally be ,:he tank
<br /> owner, DIAL ACTION
<br /> Indicate+which action Have been used to cleanup or remediate the leak.
<br /> SITE LOCATION Descriptions of options fall
<br /> Enter information regarding the facility. 'At a minimum, you mast
<br /> provide the facility name and full address, Cap Site - install horizontal impermeable layer to reduce rainfall
<br /> infiltration.
<br /> IMPLPgNTING AGENCIES ContainmentBarrier - 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. P and Treat Groundwatar - generally employed to remove dissolved
<br /> contaminants,
<br /> DISCO Y/Ai3ATETIENT Enhanced Bicadegradation use of any available technology to promote
<br /> Prdvide information regarding the discovery and abatement of the leak. bacterial decomposition of contaminants.
<br /> A lace Supply - provide alternative water supply to effected parties.
<br /> SgjR CAUSE Treatment at Hooku2 - install water treatment devices at each dwelling or
<br /> Indicate source(s) of leak. Check box(es) indicating cause of leak. other place of use.
<br /> Vacuum Extract - use pumps or blowers to draw air through soil..
<br /> CASE TYPE Vent Soil - !bore hales in soil to allow volatilization of contaminants.
<br /> Indicate the case type category for this leak. Chleck one box only. Case No Action Aecnuired - incident is minor, requiring no remedial action,
<br /> type is basad on the most sensitive resource affected_ For example, if
<br /> both soil and ground water have been affected, case type will be "Ground COMMENTS - Use this space to elaborate on any aspects of the incident,
<br /> Water". Indicate "Dr nking Water" only it one or more sssmnicipal or
<br /> domestic water wells have actually been affected. A "Ground Water" SIGNAT” —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 'nater, but only that water wells have not yet been iIISTRBUTIO
<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 forward the remaining copies intact to your local,tank permitting agency
<br /> for distribution,
<br /> C NT STATUS 1. Original - Local T Permitting Agency
<br /> Indicate the category which best describes the currentstatus of the case. 2. State Water Resources Control Board, Division of Clean Water Programs,
<br /> Check one box only. The response should be -relative to the ease type. For Underground Storage Tank Program, P.O. Box 944212, Sacramento, CA 94244-
<br /> example, if case type is "Ground Water" tier '*Current Status" should refer 2IZD
<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 captions fol' 4. Local Health Officer and County Board of Supervisors or their designee to
<br /> receive Proposition 85 notifications.
<br /> No Aericn Taken - No action has 'been taken by responsible party beyond 5,, Owner/iesponsible party.
<br /> initial:report of leen,
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