MO-4641_15664_CA_UST-61_19940228_Pollution Incident-UST Leak Reporting Form

POLLUTION INCIDENT/U.S.Te LEAK REPORTING FORM
OepoAmerrf d Emromwd, % oom, Ndurd Remumes Cam• GW Contaminchor�lQ 'N) L-' haident* l S(ob
Obtsiw of Errvlronme Manownwd Major Sol Contomfnahor&4)
GROUNDWATER ti f_T minor sal Contorni^xatin (v/t� Date Incident Occur o % Z
a Look Detected
INCIDENT DESCRIPTION
�tll T-Y
Inaldent LocadioryName C o L i S G fi i 4 /L 0 oq�
Address Z 10
C O G 7-5 G 14 Tit /L O f} /�
cry/rown C r�4tc�1=4 co�„tl, /1'Ik �c t'j�{(!3 r/2 (, aepian /1'12 D
&*N Domerlbe hddent O i od /L •+t o dit-c o r 0,VC Z S 0 - G/f c t-&V �f i �-r►�v
O C> $ SP s c c i,ns��Td uifl S ro vnrf�
6C( S Z Y0 a /° P,*J , f� i iln PdAoffi '7' Af erc( Z- � : WZ�6 s Iforr 0 Titk
FocCoVv �/l/ G� wrr �rlcY i9 (/0 /�YflcYs�S Gv6!-S
rrt r1- ova+ Pn %&.41,h�f N o �o oz /,v�+ S Unit /L vA1
POTENTIAL SOURCE OWNER -OPERATOR Telephone
FC=r-
ce Owner -Operator L G,F, /10 LvAl� r%1 7o N 36 2 - Sb 00
%/� s ,I oo t cAr y Co �� 1 �( Strest�4ddr 5 3 r% R ✓ `� /l �tD S � 2 00
C"YG H-Iml L e ! i k Coulty � �/t ca+�!%3 U 2(, State _C zip Cade Z 1 a
OWNERSHIP 7. State
0. N/A 1. Mun`cipol 2. Military 3. Unknown 4.Private 6.Federd 6. County
OPERATION TYPE
0. N/A 1. Pubic SenAce 2. Agricultrvd 3. Reeidw-Md 4. Educational/Reig. 6. kxkxtrid 6. Commercial 7. Miring
POLLUTANTS INVOLVED
AMOUNT LOST
AMOUNT RECOVERED
MATERIALS tNVOLV®
SOURCE OF POLLUTION
�NG
PRIMARY SOURCE OF POLLUTION
(Select one)
1. htentional dump 13. Wei
(SeieARY e) I UT�1�E
(select one)
1. Pent ide/herbicide
=OCAMON
1. Fodlty
1. Reddentid
2. Pit. pond, lagoon14. Dredge sPol
2. RodiooctNe waste
2. Ralirood
2. hdu dal
3. Look -underground 16. Nonpoint source
3. ne/diesel
3, Waterway
3. Urban
4. Spray lion
4'
4. pine
4. Rud
6. Lond appicatbn
6. Other petroleum prod.
6. Dumpsite
6. Animd f1eedot
6. Sewoge/septoge
6. H04wary
7. Source unknown
7. FerMen
7�R":dw:45
s. Septic k r*
A. sludge
9. Sewer lho
9. Solid waste Ieochote
10. Stodppie
10. Metals
Site Priority
11. LandW
11. Other Inorgariics
Rang (
IIUV
12. Spil-surface
12. other orgaNcs
D.E.M. R onal Contact
Signufur
Date
GW-61 Revised 3/92

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