|
INSTRUCTIONS
<br />0' E t(3'ENCY
<br />Indicate whether eme,gQn'acy response personnel and e=quipment were involved
<br />at amy time. 1-f so, a hazardous Mater:.al incident Report should be filad
<br />with the State Office of Eme*'gency Services (GES; at 285)} Hoadowview Road
<br />Sacraments, CA 95832. Copies of the GES re*,c>,t. form may be obtained at
<br />your local underground s'.orage tank permitting agency. Indicate whether
<br />the OES report has been: fi ed as of the date of this report.
<br />LOCA. AGENCY ONLY
<br />To avoid duplicate notifica-don pursuant to Health and Safety code Section
<br />25180.5, a government emoloyene, should sign and data the form in this block.
<br />A s .gnature ,ere does not .lean that.
<br />ha , th.e 1eL, has been, determined to pose a
<br />significant threat tp human ai.th or safety, only that, notification
<br />procedures have; been followed if required.
<br />RTPORTED BY
<br />in ertour name t. } Y: m ber, and ad re 5. Zudicate which party ycc;
<br />vis,_. i?5e aU azl Provide company or agency name.
<br />RESPc?PdSIBLn_S PARTY
<br />En er
<br />name, i e ,ephone number, contact person, and address of the
<br />U'rty
<br />responsible for the leak. ltk ; responsible party would normally be the tank
<br />owner.
<br />SITE LOCATION
<br />Titer a. '.orma`uicn re ardin�T the tank facil:i.ty, At a T.,iaimum, you ^lust
<br />t,rovide the ?:ety e ? tull address.
<br />!::.tem ...asmes of the local agency and Regional Water Quality =on;,rull Board
<br />i<:vclvod.
<br />SUBSTANCES !NVCLV2JD
<br />.meter the nay.>.c and quantity lost of the h.zazdo—,s substance involved, Ro mem
<br />Is pr mti_:Fe1 fur information a,two subst_..,,.ss ,.f appropriate. If more than
<br />two substances leaked, 11st the two of nmost concern for Cleanup.
<br />D1SCCVERY/ABATEM^NT
<br />Provide information regarding the discovery and abatement of the leak,
<br />SOURCE;CAUSE
<br />,^,Indicate source(s) of leak. Check box(es) indicat'ng cause of Leak.
<br />CASE TYPE
<br />Indicate t;he case type category 'for this Leal. Check one box only. wase
<br />ty e is based on the most sensitive resource affected. For example, i_
<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 "Ground Water"
<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
<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 current status of the case.
<br />Check one box only. The response should be relative to the case type. For
<br />example, if case type is "Ground Water" then "Current Status" should refer
<br />to the status of the ground water investigation or cleanup, as opposed to
<br />that of soil. Descriptions of: options follow:
<br />No Action Taken - No action has been, taken by responsible party beyond
<br />irmiti<=.l
<br />report of =eakc
<br />Leak Bein Confirmed - Leak suspected at site, but has not been confirmed.
<br />PreWimi:,ary Siie Assessment Workplan Submitted - workplan/proposal
<br />requested oflsubanztted by responsible party to determine whether ground
<br />water has been, or will be, impacted as a result of the release.
<br />Pral.iminar Site Assessment Underway - implementation of workplan.
<br />Pollution Characterization - responsible party is in the process of fully
<br />defining the extent of contamination in soil and ground water and assessing
<br />impacts on surface and/or ground water.
<br />Remediat.i.on Plan remediation playa 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 Cleaner. Monitari.ng zn Progress - periodic ground water or other
<br />monitoring at site, as necessary, to verify and/or evaluate effectiveness
<br />of remedial activities_
<br />Case Closed - regional beard and Local agency in concurrence Haat no
<br />further work is necessary at the site.
<br />IMPORTANT: THE INFORMATION PROVIDED ON THIS FORM IS INTENDED FOR GENERAL
<br />S'TA" ISTICA.L PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REPRESENTING THE
<br />OFFICIAL POSITION Gr' ANY GOVERNMENTAL AGENCY
<br />REMEDIAL ACTION
<br />indicate which action have been used to cleanup or remediate the leak.
<br />Descriptions of options follow:
<br />v"ap Site - install horizontal impermeable layer to reduce rainfall
<br />infiltration.
<br />Containment Barrier - instal.! vertical, dike to block horizontal movement of
<br />contain nano.
<br />Lx
<br />,Eavate and Dispose - remove contaminated soil and dispose in approved
<br />site.
<br />Exca✓ate and Treat - remove contaminated soil and treat (includes spreading
<br />or land farming),
<br />Remove Free Product - remove floating product from water table.
<br />Pump and Treat Groundwater - generally employed to remove dissolved
<br />contaminants,
<br />Enhanced Biodegradation - use of any available technology to promote
<br />bacterial decomposition of contaminants.
<br />12eplace Supply - provide alternative water supply to affected parties.
<br />Treatment at Hookup -- install water treatment devices at each dwelling or
<br />other puce of use.
<br />Vacuum Extract - use pumps or blowers to draw air through soil.
<br />slant Soil - bore holes in soil to allowvolatilization of contaminants.
<br />No Action Rewired - incident: is minor, requiring no remedial action,
<br />got-1,1ENTS - Use this space to elaborate on any aspects of the incident.
<br />SIGNATURE - Sign the form in the space provided,
<br />DISTRIBUTION
<br />If the form is completed by the tank owner or his ascent, retain the last copy
<br />and forward the remaining copies intact to your local tank permitting agency
<br />for distribution.
<br />i. Original - Local. Tank Permitting Agency
<br />2. Regional Water Quality Control. Board
<br />3. Local Health Officer and County Board of Supervisors or their designee to
<br />receive Proposition 65 notifications.
<br />4, weer/responsible party.
<br />
|