COMPLIANCE INFO_1986-2005 - Laserfiche WebLink

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0 INSTRUCTIONS EMERGENCY CURRENT STATUS 'nhd'cate whether emergency response personnel and equipment were involved at Indicate the category which best describes the current status of the case. any time. If so, a Hazardous -Material Incident Report should be -with Check one box only. The response should be relative o the case type. For -filed the State Office`of.Emergency Services (DES) at 2800 Meadow.view, Road, example, if case type ,is "Ground Water", then "Current Status" should refer to Sacramento, CA 95832. .Copies of the OES report form maybe obtained at Your_ the status of the ground water in or cleanup, as opposed to that of local underground .storage tank permitting agency. ..Indicate whether the•,OES soil. report has been filed as of the date pf this report. v- IMPORTANT: THE INFORMATION PROVIDED ON THIS FORM IS INTENDED FOR GENERAL LOCAL AGENCY ONLY ` STATISTICAL PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REPRESENTING THE ,. ft To avoid duplicate notificationpursuant to'.Health-and Safety .Code Section OFFICIAL POSITION OF ANY GOVERNMENTAL AGENCY 25180.7, a designated government employee should sign and•date-the form in v ;ti this block. A signature here does not'mean.;that the leak `has been determined" to a significant threat to human health or safety, only that notification` REMEDIAL ACTION, Indicate which actions have been used to cleanup or remediate the leak. pose procedures have been followed if required. "'. " Descriptions of options follow: .> REPORTED BY _Cap ____Site - install horizontal impermeable layer to reduce rainfall -Enter -your name, telephone number, and address. Indicate -which party you i nti on . 4 represent and provide company or agency name. Containment Barrier - install vertical dike to block horizontal movement of contaminant. ' RESPONSIBLE PARTY Excavate and Dispose - remove contaminated` soil and dispose in approved Enter name, telephone number,, contact person, and address of the par$y responsible for the leak. The responsible party would normally be the tank ` -site• Excavate and Treat - remove contaminated soil and treat Procludes „ owner. spreading or lana, farming): Remove FreeiP,roduct - remove floating product from water w SITE LOCATION to e. Fin r n ormation regarding the tank facility and surrounding area. At a Pum and _Treat Groundwater = generally employed to remove dissolved - minimum, you must provide the facility name and full address. contaminants. Enhanced Biodegradation - use of any available technology to promote IMPLEMENTING AGENCIES bacterlai cFecomposition of contaminants. Enter names of t e ocaT agency and Regional Water Quality Control Board Replace Supply - provide alternative water supply to affected involved. parties. Treatment at Hookup - install water treatment devices at each dwelling or SUBSTANCES INVOLVED oti�er pace o -use. °' Enter the name and quantity lost of the hazardous substance involved. Room is No Ac tion :Re wired - incident is minor, requiring no � i provided for information on two substances•if appropriate. If more than two ' rem c�ia�action. '-f substance's leaked, list the two of most concern for cleanup. COMMENTS - Use this space to elaborate on any aspects of the incident. DISCOVERY/ABATEMENT 3TWA RE - Sign the form in the space provided. FProvide information regarding ,the discovery and abatement `of the leak. MURTBFUTION SOURCE/CAUSE y If the form is completed by the tank owner or his agent, retain the last copy ndicate source(s) of leak. Provide details on tank age; capacity and and forward the remaining copies in tact to your local tank permitting agency material if known. Check boxes) indicating cause of leak.. _ for distribution. ' 1. Original -":Local Tank Permitting Agency CASE TYPE 2. State Water Resources Control Board, Division of Water Quality, . In iicate the case type category for this leak. Check one box only. Case type Underground Tank Program, P. 0. Box lOQ, Sacramento, CA 95801 is based on the most sensitive resource affected. For examplo,•if both soil 3. Regional Water Quality Control Board and ground water have been affected,case type will be "Ground Water"., 4. County Board of Supervisors or designee to receive Proposition 65 Indicate ".Drinking Water" only if one or more municipal or domestic water notifications. ' wells have actually been affected. A "Ground Water" designation does not 5. Owner/responsible party. - imply that the affected water cannot be, or -is not, used for drinking water, but only that water wells have-not yet beer affected. It is understood that case type may change upon further investigation.