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INSTRUCTIONS
<br />EMERGENCY
<br />Indicate whether emergency response personnel and equipment were involved
<br />R at any time. If so, a hazardous Matekial--Incident Report shogld be -filed
<br />with the State Office of Emergency Services (OES) at 2800 Meadowview Road,
<br />Sacramento, CA 95832, Copies of the OES report form d.a be obtained•at
<br />your local underground 'storage tank permitting agency. -Indicate whether
<br />the OES report has t3an filed as of the date of this report.
<br />LOCAL AGENCY ONLY
<br />To avoid duplicate notific tion pursuant t6Ziealth and Safety code Section
<br />25180.5, a government empl;yes should sign and date the form in this -block,
<br />A signature here does notimean that -the leak has been determined to pose a
<br />significant threat to hwgan health -or safety, only that notification
<br />procedures have been followed if required. .
<br />REPORTED BY -
<br />Enter your name, telephone number, and address. -Indicate which part';7 you
<br />represent and provide company or ag-66ncy name.
<br />RESPONSIBLE PARTY.
<br />-'Enter name, telephone number, contact person, and address of the party
<br />,responsible for the leak. The responsible party would bormally be the 'tank
<br />owner. i
<br />SITE LOCATION
<br />Enter information regarding the tank facility. At a minimum., You must
<br />provide the facility name and full. address.
<br />IMPLEMENTING AGENCIES
<br />" Enter names of the local agent*-anCRegional•Water Quality Control Board
<br />involved.
<br />SUBSTANCES INVOLVED ,
<br />Enter the name and quantity lost of the hatardous substom e involved. Boors
<br />is provided for information on -two substances if appropriate. If Tmore th'am,
<br />two substances leaked, list thetwo-of most concern for cleanup.
<br />DISCOVE,RYIABATEMENT _ -
<br />Provide information regarding the discovery and abatemett of the leak.
<br />SOURrr,,r?U:k'. r
<br />indicate sourtes) of leak. Check box(es) indicating cause tf leak.
<br />CASE TYPE
<br />Indicate the case type category'•for this leak. Check one box only. Care
<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
<br />Water". Indicate "Drinking Water",only if one or more municipal or
<br />domestic water wells have actually been affected. A "GiZound Slater"
<br />designation does not imply that 'the affected water cannot bey, or is not,
<br />used for drinking water, but only that water wells haveinot yet been
<br />affected. It is understood that case type may change upon further
<br />investigation. ?
<br />CURRENT STATUS
<br />Indicate the category which best,_describes the torrent Status of the case_
<br />Check one box only. The respcly e should be relative to the case type. For
<br />example, if case type is "Ground Water", tkcn "Current Status'" should refer '
<br />to the status of the ground water investigation- or cleanup, as opposed to
<br />that of soil. Descriptions of."ppti�ows foilovt:
<br />No Action Taken - No action•fias been talon by responsible -party beyond
<br />initial report of leak,
<br />Leak Being Confirmed - Leak suspected at site, but has not been confirmed.
<br />Preliminary Site Assessment Workplan Submitted - workplan/proposal
<br />requested of/submitted by responsible party to determine whether ground
<br />water has been, or will be,, .impacted as a result of the release.
<br />Preliminary Site Assessment Underway - implementation of workplan,
<br />Pollution Characterization - responsible party is in the process of fully
<br />defining i,he extent a-' coni,amination in soil and ground water and assessing
<br />impacts on surface and/or 'ground water.
<br />Remediation Plan - remediation elan submitted evaluating long term
<br />remediation options. Proposal and implementation schedule for appropriate
<br />remediation options also submitted.
<br />Cleanup "Underway - implementation of remediation plan,
<br />Post Cleanup'Mobitoring, in PrPr„ ogr ss - periodic ground water or other
<br />monitoring at site, .as necessary, (,o verify and/or evaluate effectiveness
<br />of remedial activities.
<br />Case Closed - regional board and local agency in concurrence that no
<br />further work is necessary 'at the site,
<br />IMPORTANT: THE INFORMATION PROVIDED ON THIS FORM IS INTENDED FOR GENERAL
<br />STATISTICAL PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REPRESENTING THE
<br />OFFICIAL POSITION OF ANY GOVE;RFMENTAL AGENCY
<br />REMEDIAL ACTION
<br />'Indicate action have peen used to cleanup or remediate the leak.
<br />Descriptions of options fo,Low:
<br />Cap Site - install hoAizontal impermeable layer to reduce rainfall -
<br />infiltration,
<br />Containment Barrier - install vertical dike to block horizontal movement of
<br />contaminant. - -
<br />Excavate and bsaosr: ., rempvc contaminated soil and dispose in approved
<br />site.
<br />Excavate and Tract - remove contaminated sail and treat (includes preading
<br />or land ._arming).
<br />Remove Free Product remove floating product from water. table.
<br />Pump and Treat Groundwater.- generally employed to remove dissolved,
<br />contaminants.
<br />nhancei BicicPrac,:t.i.on -- pse of any available technology to promote
<br />bacterial decoirposition of contaminants.
<br />Replace Suu)zily - provide alternative water supply to affected parties.
<br />r st t r rqk o to La l water treat ent devices at each dwelling or
<br />other et pI . f e.
<br />.u, h T, a Use pumps! or blowers to draw air through soil.
<br />Vent Soil - bore holes in soil try allow volatilization of contamifants.
<br />N�i R:-< :�:ed incident is -minor, requiring no remedial-'actign.
<br />CO!- ENTS - Use this space to elaborate on any aspects of the incident..
<br />SIGNATURE Sign the form in the space provided.
<br />DIZIT IBUTION- ,
<br />':I�f' the form is completed 1l.y the tank owner or his agent, retain the last copy
<br />and forward the remaining copies intact to your local tank permitting agency
<br />"for distribution.
<br />,1. Original - Local Tar)1,Permitting Agency
<br />'l., State Water Resources Control Board, Division of Clean Water Programs,
<br />Underground Storage,Tank Program, 'P.O. Box 944212, Sacramento, CA 94244-
<br />2120
<br />3. Regional Water Quali,ty Control Board
<br />4. Local Beal' h Officer_and Cotuity Board of Supervisors or their designee to
<br />receive Preposition as ;otl*fit,t ons.
<br />`.i. Owner/responsible pasty.
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