MO-5333_18508_CA_UST-61_19980330_UST Leak Reporting Form

POLLUTION INCIDENT/U.S.T. LEAK REPORTING FORM
Department of Environment, Health, Natural Resources
Confirm. GW Contamination (Y/N)
Incident#' o s�
Division of Environmental
GROUNDWATER SECTION
Management
Major Soil Contamination (Y/N)
Date Incident Occurred
0/�7�
Minor Soil Contemineti (Y ) Z_­-
or Leak Detected
INCIDENT DESCRIPTION
Incident Location/Name L 2Fy S S �-h/Z'TS
Address
(o Z S G v;_-H A 1/OA( �(
City/Town C f7}4 eU� / %
County IWIL LK L V 3, iIJLv Region /1�/2Q
Briefly Describe Incident 14A L t 41110 U,L Oe- p lb'K( ,S'/07-7 L &l461c Gi20,4 fit./
0r
oSCL -f�AlJ41 C�Z7(_ US %-1 7- Uvi Dr- U1/7-
->�
k !v�
C CO�k✓� w +� vni 4 C�a S 77}rt[Q �? S S�� i S �S ! ! 'V u2S:-�C6
�m h,
POTENTIAL SOURCE OWNER -OPERATOR
Pctentici Source Owner
-Operator i7t1 N U/l. S CE 1 I Telephone
Qr�c2�S s�tk�.; J
J
Company
Street Address
cityGi�ft� �/(
I County
CKEf 3U�6
I State / I ZpCcce
�
OWNERSHIP
0. N/A 1. Municpcl
2. Military 3. Unknown 4.Private 5.Federal 6. County 7. Stare
/A 1 Pubiic Service 2. Agricultrural 3. Residential 4. Educational/Relig. 5. Industrial 6. Comrnercicl 7. Mining
POLLUTANTS INVOLVED
MATERIALS INVCLVED
% AMOUNT LO AMOUNT R= OVci<e�
SOURCE OF POLLUTION
PRIMARv SOU^< = OF PO TION
(Select cne)
PRIMARY POLLUTANTTYoG
LOCATION
S iTIN
(Select one)
1. Pesticide/herbicide
1. Intentional dump
13. Well
1. Facility
1. Resicential
2. Pit, pcnd, lagoon
14, Above -ground
Storage Tank
2. Radioactive waste
2. Railroad
2. Indus -rice
3. Leck-,:ndergrcund
3. Gasoline/diesel
3. Waterway
Urbc^'
4. Spray irigation
15. Nonpoint source(:
=H,,t,,g
4. Pipeline
4. Rurc
5. Land application
5. Other petroleum prod.
5. Dumpsite
6. Animci feedlot
6. Sewcge/septcge
6. Highway
7, Source unknown
7. Fertilizers
. Residence--
8. Septic tank
8. Sludge
8. Other
9. Sewer line
9. Solid waste leachate
10. S1cczciie
10. Metals
Site Priorrty
11. Lc ^'ii
11. Other inorganics
Ranking J
�. Seiil uTc�=
12, Other organics
tJ---
D.E.M. Re^i ci ContccY
Signatur Date
�' ✓ 61 ;.�.._ec 2/9;z

IMPACT ON DRINKING WATER SUPPLIES
WELLS AFFECTED 1. YES 2. NO
NUMBER OFWELU c AFFECTED
WPII(s) Contcmin d• (Use7 Name)
1.
2.
3.
4.
Circle Appropriate Responses
Lab Samples Taken By:
Samples Taken Inc!ude:
7 1/2 Min. Quad Nome
S Min. Quad Number
1. DEM 2. DHS
1. Groundwater 2. Soil
3. Responsible Party 4. Other U. None
LOCATION OF INCIDENT
12 : Deg : Min : Sec :
Lora.: Deg: Min: Sec :
Draw Sketch of Area or Attach Additional Maps
14
.rl G �•- � 4 a.. it

24 HOUR REPORT
DATE MOE
TIME F 0 d 4 Al
LOCATION OF TANK Z S U T tI � /L' ,,YV S ! !C 4 ,e,,, I -
COUNTY /174-61k t-4vf3vl7 G CITY C��fi�/L i / /-
TANK OWNER/OPERATOR D r t 62lt5 S i"� TS v✓L S{�, /��,
ADDRESS � I L S vy; I- R-1 y7 -4 9 7n4/, i
CITY C lf/lly r i At L
PHONE
NATURE OF RELEASE fff, - ,7A-(6 0 L U,0Odk,4
TYPE OF PRODUCT RELEASED �W G dy l�
AMOUNT LOST ON kl1yoaA(
DATE OF RELEASE DATE RELEASE DISCOVERED -3/ 3G 0 P
SUSPECTED RELEASE YES_ NO_ IF YES EXPLAIN
CONFIRMED RELEASE YESX NO_ IF YES EXPLAIN
WATER SUPPLY IN AREA WELLS HOW MANY
DISTANCE
CITY/COUNTY YES_ NO_
NOTE: 1)IF SUSPECTED RELEASE FOLLOW 280.52
A. SYSTEM B. SITE CHECK
2)IF CONFIRMED RELEASE FOLLOW 280.61 - 280.63
PERSON REPORTING RELEASE T OF Its C/< — m C (olet

DIVISION OF WASTE MANAGEMENT
I
UST SECTION
•'MOORESVILLE REGIONAL OFFICE
FILE REVIEW NOTES
Site: dg, t U%G'`��f �'��'� "4 1 Reviewed by:
Location: % (' / 2 S �' Tom- S l Date Reviewed: I 3 /0 L
C 117�4 LEA �i%2
Incident #: I b' 5 0 r
0T=::: (-S I T-.,
Li J / % 0 e