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HomeMy WebLinkAboutMO-4641_15664_CA_UST-61_19940228_Pollution Incident-UST Leak Reporting FormPOLLUTION 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. 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