UST Unauthorized Release (Leak) / Contamination Site Report

UNDERGROUND STORAGE TANK (UST) SITE - UNAUTHORIZED RELEASE / CONTAMINATION

EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICESREPORT FOR LOCAL AGENCY USE ONLY Yes No REPORT BEEN FILED? Yes No I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF THE HEALTH AND SAFETY CODE. REPORT BEEN FILED?

YES NO REPORT DATE CASE #

SIGNED DATE NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE ( ) Y B REPRESENTING COMPANY OR AGENCY NAME D E

T LOCAL AGENCY REGIONAL BOARD R

O OWNER/OPERATOR OTHER P

E ADDRESS R STREET CITY STATE ZIP E

L NAME CONTACT PERSON PHONE B I

S Unknown N ( ) O

P ADDRESS S E

T STREET CITY STATE ZIP R A P FACILITY NAME (IF APPLICABLE) OPERATOR PHONE

N ( ) O I

T ADDRESS A C

E STREET CITY COUNTY ZIP T I

S CROSS STREET

G LOCAL AGENCY AGENCY NAME PHONE N I T N

E ( ) M E L

P REGIONAL BOARD PHONE M I S E I ( ) C N E G A

S (1) NAME QUANTITY LOST (GALLONS) E C N

A Unknown T S

B (2) U S D

E Unknown V L O V N I

T DATE DISCOVERED HOW DISCOVERED N Tank Test Tank Removal Nuisance Conditions E

M Inventory Control Subsurface Monitoring Other

A DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) B A / Remove Contents Close Tank Y

E Unknown Repair Tank Change Procedure V

O HAS DISCHARGE BEEN STOPPED? Replace Tank Other C S I Yes No IF YES, DATE Repair Piping D /

E SOURCE OF DISCHARGE CAUSE(S) C R U O

S Tank Piping Dispenser Delivery Problem Spill Overfill Physical/Mechanical Damage Corrosion E S Submersible Turbine Pump (STP) Other Installation Problem Unknown Other U A C

E CHECK ONE ONLY S A C E

P Undetermined Soil Only Groundwater Drinking Water – (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) Y T

S CHECK ONE ONLY U T

A Open - Site Assessment Open - Verification Monitoring T S Open - Assessment & Interim Remedial Action Open - Inactive

E Open - Remediation Closed – No Further Action Required R R U C CHECK APPROPRIATE ACTION(S) SWRCB Leak Report Form http://www.swrcb.ca.gov/water_issues/programs/ust/forms/ Rev. 02/01/2012 REPORTED BY REPORTED been if notification followedrequired.have only that procedures safety, health human or here signature A block. this in form the date and sign should employee ONLY USE AGENCY LOCAL report. this of date filedas OES report the has of been Indicate the Services (OES).whether Emergency Office of Statefiledwith the be should EMERGENCY SWRCB Leak ReportFormSWRCB REMEDIAL ACTION TO NOT IS AND POSITION GOVERNMENTALOF ANY AGENCY. REPRESENTINGCONSTRUED AS BE THE OFFICIAL ONLY PURPOSES STATISTICAL GENERAL FOR INTENDED IS FORM THIS ON PROVIDED INFORMATION THE IMPORTANT: or investigation water ground the of Descriptions follows: soil. optionsas of of are opposed that to as cleanup, status the to refer should Status Current then “Groundwater,” is Type Case the if example, For Type. Case the to STATUS CURRENT for used not, is or be, cannot water affected the that imply furtherchange investigation. is understoodCase Type mayupon affected. It that not wells been water have yet water, but that only drinking not does designation “Groundwater” A affected. been actually have wells water domestic or municipal more or one if only Water” “Drinking Indicate “Groundwater.” be will Type Case affected, been have water ground and soil both if example, TYPE CASE vent from vaporreleases and recoverylines. CAUSE SOURCE: DISCOVERY/ABATEMENT cleanup. forconcern most of INVOLVED SUBSTANCES AGENCIESIMPLEMENTING LOCATIONSITE normally tank owner.wouldbe the PARTY RESPONSIBLE SIGNATURE

         REMEDIAL ACTION COMMENTS unacceptable human exposure pathways at the site.human pathways theat unacceptable exposure site. exposure humanthe these pathways address entire to for actions be to completed humans, andyet to have exposures conditions.forsitedetermined current controlagency the is under staff has BoardotherRegionalWater regulatory or theQuality Control and thework at is necessary site.further activities. or the environment.or health anhuman address immediateto appropriateactions threat theand of prevent resultrelease to a as impacted release.the Groundwatermigration control? Human health exposure control? : :

Check box(es) that apply. Only use “other” when the release “other”source box(es)does Only the fitof categories. that the apply. use isknown,not Check but other Forexample when intoany Excavate &Dispose Excavate (ED) (NAR)No Action Required Human health exposure control? Unknown control? exposure health Human No control? exposure health Human Yes control? exposure health Human – Required Action Further No Closed- Inactive – Open- – Monitoring Verification Open- Remediation – Open- – Action Remedial Interim & Assessment Open- – Assessment Site Open- Indicate the source(s) of theof leak. source(s) Indicate the : : Check one box only. Indicate the Case Type category for this leak. Case Type is based on the most sensitive resource affected. For affected. resource sensitive most the on based is Type Case leak. this for category Type Case the Indicate only. box one Check Sign the form in the space theprovided. form space inSign the : : Instructions for Completing UST Unauthorized ReleaseInstructions for Completing Unauthorized /Site UST Report (Leak) Contamination Indicate whether emergency response personnel and equipment were involved at any time. If so, a Hazardous Material Incident Report Incident Material Hazardous a so, If time. any at involved were equipment and personnel response emergency whether Indicate : Enter name, telephone number, and address. Indicate which party you represent and provide company orcompany agency party you provide name.whichrepresent and telephoneaddress. Enter Indicate and name, number, : Enter information regarding the tank facility. At a minimum, you must provide the facility name and full site must namefulla the address. and Atfacility.provide facility minimum, youthe Entertank information regarding : : Check one box only. Indicate the category which best describes the Current Status of the case. The response should be relative be should response The case. the of Status Current the describes best which category the Indicate only. box one Check Indicate which actions have been used to clean up or remediate the leak. Descriptions of options are as follows: options astheofare leak. usedup Descriptionshaveor Indicate actionsclean remediate which to been : Enter the name, telephone number, contact person, and address of the party responsible for the leak. The Responsible Party Responsible The leak. the for responsible party the of address and person, contact number, telephone name, the Enter : : : No activities have been implemented to determine whether groundwater and/or soilthegroundwaterand/or determinewhetherwere/was by release.toimpacted No been implementedactivities have Provide information regarding the discovery and abatement of the leak. Provide abatementthe discovery of and information regarding the Enter the name and quantity lost of the hazardous substance(s) involved. If more than two substances leaked, list the two the list leaked, substances two than more If involved. substance(s) hazardous the of lost quantity and name the Enter : Enter the names of the local agency and Regional Water Quality Control Board having jurisdiction over the site. having jurisdiction Quality theControl Board over names Regional theWater agency Enterof and local the : To avoid duplicate notifications pursuant to Health and safety Code Section 25180.7, a designated government designated a 25180.7, Section Code safety and Health to pursuant notifications duplicate avoid To Remedial activities to prevent or address a threat to human health or the environment as a result of the release.a as thethe of result environment health address human orto threat Remedial prevent oractivities to a An investigation to determine whether groundwater and/or soil have/has been, or will be, impacted as a result of result a as impacted be, will or been, have/has soil and/or groundwater whether determine to investigation An Yes Yes Yes Yes Free Product Free (FPR)Removal TreatExcavate & (ET) Periodic groundwater or other monitoring at the site to verify and/or evaluate the effectiveness of remedial of effectiveness the evaluate and/or verify to site the at monitoring other or groundwater Periodic Check that apply. sourc(es) http://www.swrcb.ca.gov/water_issues/programs/ust/forms/ No No – – – Regional Water Quality Control Board and local agency Local Oversight Program agree that no that agree Program Oversight Local agency local and Board Control Quality Water Regional Assessments for human exposures indicate there are no unacceptable human exposure pathways exposure human unacceptable no are there indicate exposures human for Assessments Data indicate that there are complete human exposures pathways that present unacceptable present that pathways exposures human complete are there that indicate Data – Unknown Unknown There is not sufficient information to determine whether there are any current, complete current, any are there whether determine to information sufficient not is There An investigation to determine whether groundwater and/or soil have/has been, or will be, will or been, have/has soil and/or groundwater whether determine to investigation An does not does mean that the leak has been determined to pose a significant threat to threat significant a pose to determined been has leak the that mean Replace (RS)Supply atTreatment Hookup (TH) Other Rev. 02/01/2012 Rev.

 Groundwater migration control? Yes – All information on known and reasonably expected groundwater contamination has been reviewed and that the migration of contaminated groundwater is stabilized and there is no unacceptable discharge to surface water and monitoring will be conducted to confirm that affected groundwater remains in the original area of contamination.  Groundwater migration control? No – All information on known and reasonably expected groundwater contamination has been reviewed and that the migration of contaminated groundwater is not stabilized.  Groundwater migration control? Unknown – There is not sufficient information to determine whether the migration of contaminated groundwater is stabilized.  No Action Required (NAR) – Incident is minor, requiring no remedial action.  Excavate and Dispose (ED) – Remove contaminated soil and dispose at approved facility.  Excavate and Treat (ET) – Remove contaminated soil and treat (includes spreading or land farming).  Free Product Removal (FPR) – Remove floating product from water table.  Treatment at Hookup (TH) – Install water treatment devices at each dwelling or other place of use.  Replace Supply (RS) – Provide alternate water supply to affected parties.  Other – Other remedial actions that are not listed above.

COMMENTS: Use this space to elaborate on any aspects of the incident.

DISTRIBUTION: If this form is completed by the tank owner or his/her agent, retain a copy and forward the original to your local tank permitting agency for distribution.  Original – Local UST permitting agency. (Agency contact information is available at http://www.calcupa.net/services/directory/search.asp.)  Copy – Regional Water Quality Control Board. (Boundaries and contact information are available at http://www.waterboards.ca.gov/waterboards_map.shtml.)  Copy – Local Oversight Program (LOP) agency. (Agency contact information is available at http://www.waterboards.ca.gov/water_issues/programs/ust/contacts/lop.shtml.)  Copy – Local Health Officer and County Board of Supervisors or their designee to receive Proposition 65 notifications.  Copy – Owner/Responsible Party.

SWRCB Leak Report Form http://www.swrcb.ca.gov/water_issues/programs/ust/forms/ Rev. 02/01/2012