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4 <br /> - - <br /> � <br /> ` <br /> � <br /> ^ <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LE A�K) C1614TAMINATION SITE REPORT <br /> HAS STATE OFFICE OF EMERGENCY AV FOR LOCALAGEN <br /> REPORTSEENFLED? CY..USE ONLY;': -7777777777= <br /> YES JI/No YES NO <br /> WS:-INFORkATION T6LDCk�OFF <br /> ir <br /> RE A*A <br /> PHONE SGN�TU <br /> I &AVeLV 71 f-3 <br /> REPRESENTING OWNE:WERATOR REGIONAL BOYA <br /> THr <br /> Lo <br /> NfLOCAL AGENCY FEI OTHER <br /> Lu <br /> fr ADDRESS <br /> NAME crry 1�6y-kvvl/- STATE 6A 7p <br /> CONTACTPERSON PHONE <br /> 99 11 <br /> ADDRESS <br /> S 2-03 <br /> PHONE <br /> � <br /> ' FACILITY NAME(IF APPLICABLE) OPERATOR STATE <br /> tm rg ANY . <br /> � <br /> VA CROSSSTREET <br /> TYPE OF AREA Ej COMMERCIAL CK INDUSTRIAL ED RURAL TYPE OF BUSINESS RETAIL FUEL STATION <br /> RESIDENTIAL OTHER FAAM OTHER <br /> LOCALAGENFY- AGENCY NAME CONTACTIPERSON PHONE <br /> ! � <br /> ` REGIONAL 80ARD PHONE <br /> NAMEQUANTITY LOST(GALLONS) / <br /> LLb <br /> UNKNOWN <br /> UNKNOWN <br /> DATE DtSCOVE RE HOWDISCOVERED <br /> 0 TANK TEST X REMOVAL OTHER <br /> DATE DISCHARGE REGAN METHOD USED TO STOP D I ISCHARG 0(CHECK ALL T14AT APPLY) <br /> mi mi UNKNOWN D;rREMOVE CONTENTS REPLAcrm TANK CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED? REPAIA TANK REPAIR PIPING CHANGE PROCEDURE <br /> SOURCE OF DISCHARGE TANKS ONLYiCAPACITY MATERIAL CAUSF(S) <br /> TANK LEAK UNKNOWN GAL. Ej FIBERGLASS <br /> E] OVERFILL E] RUPTURE*AILURE <br /> PIPING LEM AGE YRS STEEL <br /> E] OTHER UNKNOWN OTHER <br /> CIA 0 SPILL E:1 OTHER <br /> CHECK ONE ONLY <br /> UNDETERMINED SOIL ONLY GROUNDWATER jrECKON 1, 4AVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY J <br /> SITEINVESTIIGATIIONIN "PROGRESS(DEFINING EXTENT OF PROBLEM) CUEANUPINPROGRES� SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> NoAc-noNTAKeN [:] POST CLEANUP MONfTOAING IN PROGRESS 0 ND FUNDS AVAILABLE TO PROCEED [�] EvALuATiwcLEANupALTEnNATVES <br /> CHECK APPROPRIATE ACTIDN(S)(SEE BACK FOR DETAILS) <br /> CAPSITE(C431 EXCAVATE&DISPOSE(ED) REMOVEFREEPRODUCT(FP) ENHANCED 810 DEGRADATION(IT) <br /> F-� CONTAiNMENT13ARFUER(CR) F--j EXCAVATE a TREAT(ET) PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY IRS) <br /> TREATMENT ATHOMP NO ACTION REQUIRED(NA) OTHER(OT) <br />' <br />^ <br />` <br />' <br />� <br />� <br />� <br />, <br /> ` <br />� <br />