FA-864_16314_CA_UST-61_19960927

---POLLUTION INCIDENT/U.S.T. L:AK REPORTING FORM O.partment of Environment, Heath, Natural Resources Division of Environmental Management GROUNDWATER SECTION Confirm. G W c ntomlnatlon (V/N) V Major Soll C ;mtc nlnotlon (V /N) Incident# j{p 3 Jt(--: J Minor Soll Co omlnotln (V/N) Dote Incident Occu:flTz,f) q (, or Leak Detected , INCIDENT DESCRIPTION Incident Location/Nome (i)~ g+: :' ,:pl= Ce 7 Address City/Town rL ,A ,Ht, · ~~ ~" I County ~ ~ 1 ... ~,. /J I Region V Brleflv Describe Incident .... . ----,. ~ A .... ,._ ... , , V V V POTENTIAL SOURCE OWNER-OPERATOR I T I h eep one Potential Source OWner-Operotor 'JI,,. . (2 ~ I J}~ CompSJCI' '.L Q* ".fen/ 7'IM-f: k. • Street Address f 0. 4~ f "1 <.f#._? City~,,":' .:--.o 11" I County~ State ""rJC-IZlpCode ~f5o'J-OWNERSHIP O. N/A 1. Munlclpol 2. MIiitary 3. Unknown 5.Federol 6. County 7. State OPERATION TYPE O. N/A 1. Public Service 2. Agrlcultrurol 3. Residential 4. Educotlonol/Rellg. 5. Industrial €omm':ckli) 7. Mining PRIMARY SOURCE Of PQLllJJION (Select one) 1. Intentional dump 2. Pit, pond. lagoon '3.° Leak-undergroun9 4. Spray Irrigation 5. Land appllcatlon 6. Animal feedot 7. SOurce unknown 8. Septic tonk 9. Sewerllne 10. Stockpile 11. Landfill 12. Spill-surface 13. Well 14. Above-ground Storage Tank 15. Nonpolnt source D.E.M. Regional ~_?ntqct Gef.}e;-.Tl'JCl<S~ GW-61 Revised 2/95 POLLUTANTS INVOLVED AMOUNT LOST SOURCE OF POLLUTION PRIMARY PQLLUJANT TYPE (Select one) 1. Pesticide/herbicide 2. Radioactive waste .. 6. Ga,ollne/dl~ 4. Heating oil 5. Other petroleum prod. 6. Sewoge/septage 7. Fertlllzers 8. Sludge 9. Solld waste leachate 10. Metals 11. Other lnorganlcs 12. Other organics LOCATION ~ 2. Railroad 3. Waterway 4. Pipeline 5. Dumpslte 6. Highway 7. Residence 8. Other Slgnatu~{J--!~ AMOUNT RECOVERED SEIWG. 1. Residential 2. Industrial ~ 4. Rural Site Priority Ranking O J()I)