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NS ;
<br />Leak Beim Corsfirmed - Leak suspected at site, but has not been confirmed.'
<br />Indicate waeCtaer emergency response personnel eqciprient were involved
<br />Pre' iminarY site Assessment oratti? an Submitted - .workplan/proposal ;
<br />at any time.If-so, a. -Hazardous Maternal Incident P rt should be filed
<br />requested:of/submitted by responsible party to determine whether ground
<br />with the,StaW¢ e Office of Emergency Sarv® es I.atr HQD .eau saw Road,
<br />water has been, or will- be, impacted as a result of the release.
<br />Sacramento, CA 95822, Copies of the"OEs re rt tar ;may e obtained at
<br />Pre®ascmaaary Sate Assessment Jnderssav ' implementation of workplan,
<br />t your local underground storage tank permitting asenqy. Indicate whether
<br />Pollution Characterization - responsible party is in the process of sally
<br />the OtS report has been filed as of toe date of his :effort.
<br />defining the extent of contamination an soil and ground water and assessing
<br />impacts on surface and/or ground water.
<br />LOCAL AGENCY ONLY
<br />mediation -lar& - remediation plan submitted evaluating long term;
<br />- To avoid duplicate notification pursuant to Health and Safety e':aa�tion
<br />remediation options. Proposal and implementation schedule for appropriate'
<br />25180.5, a government employee should sign mate the form in this block.
<br />remediation options also submitted.
<br />A signature here does not mean that the leak has been detarmined to pose a
<br />Cleanuxa Underway - implementation of remediation plan.
<br />significant'threat to !atnin health or safety, n
<br />- ys notification
<br />Post,Clea onitcarang zn Pro�reSS - periodic ground water or other
<br />proced:zres have been followed if required.
<br />m6nitoring at site, as necessary, to verify and/or evaluate =effectiveness
<br />of remedial activities.
<br />RE RTEII BY
<br />Case Closed - regi al board d local agency in concurrence that no
<br />near your .ame, telephone number, and address.' Indicate wh %cn party you
<br />further work is necessary at the site.
<br />epreseut'and provide company or agency name.
<br />M--RTAN T: THE INFORMATION PROVIDED ON THIS FORM IS INTENDED FOR GENERAL
<br />ELSPONSIBLE PARTY
<br />STATISTICAL PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REPRESENTING THE
<br />Enter name, telephone number, contact person,, and address of the party
<br />OFFICIAL POSITION OF ANY GOVERIWENTALAGENCY
<br />responsible for the leak, "" The esponsible party wouA no=ally be the tack
<br />owner.
<br />REMEDIAL ACTION
<br />Indicate which action have been used to cleanup or remediate the Leak.
<br />SITE LOCATION
<br />Descriptions of options foil
<br />Enter information regarding the tank facility. .z a minimum, You most
<br />provide the facility name and full ad ass.
<br />taxa" -Site - install horizontal impermeable layer to reduce rainfall
<br />infiltration.
<br />IL4NTING AGENCIES
<br />Containment Harrier - install vertical dike to block horizontal movement of
<br />Enter names of the local agency and Regional- Watez Qua_-.tx Control- Board
<br />contaminant.
<br />involved..
<br />Excavateand Dis as - remove contaminated soil and dispose in approved
<br />site.
<br />s STANCES INVOLVED
<br />Excavateand Treat: ` remove contaminated soil and treat (includes spreading
<br />Enter the name and quantity lost of the hazardoussubstance ;I'Moived. Room
<br />or land farming),
<br />is provided for information on two substances if appropriate, if more than
<br />Remove Free Product ` remove floating product from water table.
<br />two substances leaked, list the two of most concern fsrr cleanup.,
<br />PIER and Treat Groundwater - generally employed to remove dissolved
<br />contaminants.
<br />DISCO Y/ ATE[iENT
<br />E anted Biodegradation use of any available' technology to promote
<br />Provide information "regarding the discovery and obatement, of the leak.
<br />bacterial decomposition of contaminants.
<br />Agplace Supply - provide alternative water supply to affected parties.
<br />SO CE9CAUSE
<br />"Check
<br />Treatment at 22hRR - install water treatment devices; at each dwelling or
<br />Indicate source(s), of leak. box(es) i-mitcasing came of Lack.
<br />other place of use.
<br />vacuum Extract - use pumps or blowers to draw air through soil.
<br />CASE TYPE
<br />dent Soil - bore holes in soil to aflow volatilization of contaminants.
<br />Indicate the case type category for this Leak_ CZeck one box only. Case
<br />Pio Aotioaa Ite aired - incident is minor, requiring no remedial action.
<br />type is based on the -most sensitive resource affecFor er :pie, if
<br />bath soil and ground seater have been affected, case type will be "Ground
<br />CCFMNTS - Use this space to elaborate on any aspects of the incident.
<br />Water". Indicate _"Drinking Water" only if eine or niare --icipal or
<br />domestic water wells have actually been affected, A -Ground Water"
<br />SIGNATURE- 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 water, but only that water wells have not yet been
<br />DISTRIBUTION
<br />affected. It is understood that ease type maych eu1m.n further
<br />of the form is c plea by the tank owner or his agent, retain the last copy
<br />investigation.
<br />and forward the remains copies intact to your local tank permitting agency
<br />for distribution,
<br />CItRRENT STATUS
<br />1. Original - Local Tank Permitting Agency,
<br />Indicate the category which best describes the current status of the case."
<br />2. State Water Resources Control Board, Division of Clean Water Programs,
<br />Check one box only. The response should be re ative to the case type. For
<br />Underground storage Tank Program, P.O. Box 944212, Sacramento, CA 94244 -
<br />example, if case type is "Ground Water's uses -Current States' should refer
<br />21213.
<br />to the status of the ground water investigation, or cleasrup.;as opposed to
<br />3. Regional Water Quality Control. Board
<br />that of soil. Descriptions of options -f
<br />4, Local Health Officer and County Board of Svpervisots or their designee to
<br />recemve"Proposition 65 notifications.
<br />No -Action Titan No action has been taker, b7 respansible party; beyond
<br />5. Owner/responsible party.
<br />initial repol- . of leak.
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