MO-4641_15664_CA_WSW_20151021_Site Visit looking for WSWs

North Carolina Department of Environment and Natural Resources
Division of Taste Management
UST Section, Corrective Action Branch (CAB)
INSPECTION REPORT
®ate: RISK: 1.-� Inspector: h -,e1;7ZW
Site Name: XoF'OAIJ2%y Incident Number:
County: 14W'4rCi4_ UST Number:
Region: /11/4 GPS Coordinates: N W
Site Information Checklist
Facility Information:
Operating facility? Yes No
Valid UST permit? Yes No
Number of tanks: Yes No
Site map/well map verified (if no, explain discrepancies in comments section)? Yes No
Any visible spills/leaks (if yes, explain in comments section)? Yes No
Any visible water supply wells? Yes No If yes, distance to closest (ft.)?
Remediation System(s) Information:
System 1
System 2
System 3
System type?
Fully installed?
Yes No
Yes No
Yes No
Operating?
Yes No
Yes No
Yes No
Free product present (verified)?
Yes No
Yes No
Yes No
RP/consultant/other on site?
Name of RP:
Name of consultant:
Name of Other:
Pictures Taken?
Location of photos:
ime spent on site (hrs):
Yes No
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Company:
Company:
Company:
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This inspection sheet is to be placed in corresponding incident file upon completion

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