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0 IF ` 0 1�3 - fou <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICE FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED T <br /> F7 YES dN0 ❑ YES No 1 HEREBY CERTIFYTHAT HAVE DISTRIBUTED THIS INFORMATIAN ACCORDING TO THE <br /> REPORT DATE 01 . UPON OWN ONI STR TIOII HEET ON THEE K PAGE OFTHIS FORM <br /> `/J /'�) CASE, <br /> J u1 a o v J v SIGNED 5DATE. <br /> INA UAL FILING REPORT PH ±SiGNA RVV <br /> REPRES G COMPANY OR AGENCY N <br /> F ❑ OWNER/OPERATOR ❑ REGIONALBOARO /1 <br /> gLOCAL AGENCY ❑ OTHER <br /> ADDRESS <br /> �// /� <br /> / O• Q !/ OR sT♦TECiI( <br /> w N CONT TPERSON <br /> // �Q][j (PHONE <br /> 0 ❑ UNKNOWN '^��A�;6ulo l &5) <br /> Z <br /> O e ADDRESS <br /> ✓ OO� <br /> 1 FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> z z'6C' ✓ ' 3oZ , /30KiD67S LXj)367.9330 <br /> C ADDRESS <br /> r Z/ STREET AW /I ) fmc,5., Z-obl UIN ZIP — <br /> rn CROSS STREET <br /> T nr oni � <br /> _ LOCAL AGENCY AGENCY NAME CONTACTPERSON PHONE <br /> z w, fs �3Yso <br /> mm REGIONAL BOAR15 PHONE ' <br /> VA 53Gbo <br /> 1NAMEQUANTITY LOST(GALLONS) <br /> UQ <br /> �/� <br /> Fw � <br /> /L(J3 /SC -� ZI, �C!/7 �NKNOWN <br /> m o>z (2) <br /> N <br /> ❑ UNKNOWN <br /> I DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ UBSUn=A <br /> z ^ MONITORING NUI ANCE CONDITIONS <br /> h <br /> r E:] TANK TEST ❑ TANK REMOVAL OTHER <br /> a DATE DISCHARGE BEGAN / METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> o/ <br /> w H M o D r y UNKNOWN REMOVE CONTENTS �i C:CSE TANK&REMOVE REPAIRPIPING <br /> HAS DISCHARGE BEEN STOPPED T E]REPAIR TANK <br /> _I CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> U <br /> o ❑ VES ❑ NO IF YES,DATE MI u .1 <br /> r y ❑REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> �C ❑ TANK LEAK dUNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> w0 F-1PIPING LEAK ❑ OTHER ❑ CORROSION dUNKNOWN ❑ OTHER <br /> ww CHECK ONE ONLY <br /> N p <br /> O ❑ UNDETERMINED ZSOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER (CHECK ON"_Y IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> ?N ❑ NOACTIONTAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> M< ❑ LEAK BEING CONFIRMED dPRELIMINARY SITE ASSESSMENT UNDERWAY I POST CLEANUP MONITORING IN PROGRESS <br /> Uy <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) �_ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BID DEGRADATION(IT) <br /> Isf B.LR R]RGET 91 <br /> az <br /> 5 F7CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w t. <br /> w ❑ CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKJP(HU) ❑ VENT SOIL(VS) <br /> c <br /> ❑ VACUUM EXTRACT(VE) ❑0OIT�HER(OT) <br /> T�>Y7�B7G �,v'llaA✓ Tlol/ ft5 .eEgo/ �y n �'�'aJOtc� C <br /> Ns IBraN <br />