MO-5510_0_CA_UST-61_19981122_Pollution Incident-UST Leak Reporting Form

POLLUTION IN I®ENT/U,S.T. LEAK REPORTING FORM
Department of Environment, Health. Natural Resources
Confirm. GW Contamination (Y/N)
r
Incident
Division of Environmental Management
GROUNDWATER SCCTICN
Major Soil Contamination N)
Date Incident Occurred
or Leak Detected ( 1V G'V & L
Minor Soil Contamii (Y )
L?.C. 0".
INCIDENT DESCRIPTION
Incident Location/Name
Address % D
City/Town
County
` 66j/ ay
Region _ f _
Briefiv Describe Incident
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POTENTIAL SOURCE OWNER -OPERATOR Telephone
Potential Source Owner -operator '-
L33�
Company
Street Address
IoLL
City /Jya /vim
CO1^,y�PC���P
date G
Zip Code
/
OWNERSHIP
0. N/A 1. Municipal 2. Military
3. Unknown 4.PHvate 5.Federal 6. County 7. State
OPERATION TYPE
0. N/A 1. Public Service 2. Agricuttrural
Residential 4. Educational/Relig. 5. Industrial 6. Commercial 7. Mining
POLLUTANTS INVOLVED
MATERIALS INVOLVED
AMOUNT LOST AMOUNT RECOVERED
all
SOURCE OF POLLUTION
Pit Niia +�wi1RCF nF PnI 1 I mnN
I PRIMARY rQ! L(rA .IT TY--
L CC,� . CN
I STnnv-
(Select one)
(Select one)
1. Intentional dump 13. Well
1. Pesticide/herbicide
1. Faciiity
(Desidential
2. Pit, pond. lagoon 14. Dredge spoil
2. Radioactive waste
2. Railroad
2. Industrial
3. Leak -underground 15. Nonpoint source
3. Gasoline/diesel
3. Waterway
3. Urban
4. Spray irrigation
� �� f'
() Heating oil
4. Pipeline
4. Rural
S. Land application _
�� Y /
5. Other petroleum prod.
5. Dumpsite
6. Animal feedlot f✓O ��
6. Sewage/septage
6. Highway
pQ
7. Source unknown /t % it Si, l
7. Fertilizers
7. Residence
8. Septic tank d / t 13 L T
8. Sludge
(.Pother
9. Sewer line U
9. Solid waste leachate
10. Stockpile
G �'
10. Metals
Site Priority
11. Landfill .'
11. Other inorganics
Ranking
12 Spill -surface
12. Other organics
Lir uo
D Region C
Sign Date _
GJW •61 Revised 3/92 1112,2

IMPACT ON DRINKING WATER SUPPLIES
WELLS AFFECTED 1. YES
2:,NO)
NUMBER OF WELLS AFFECTED
Wells) Contaminot .d ( �� Name)
1.
2.
3.
4.
c
Circle Appropriate Responses
Lab Samples Taken By:
1. DEM 2. DHS 3. Responsible Party
4.Other
5. None
Samoies Taken Include:
1. Cround::at er 2. Scil
i
LOCATION OF INCIDENT
7 1 /2 Min. Quad Name
L(;L : Deg: Min: Sec:
5 Min. Quad Number
Lgo.CL : Deg: Min: Sec :
$0L15,-()'��
Draw Sketch of Area or Attach Additional Maps
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