WS-5015_17048_I_O_20230614

General Information:
Date:Incident No.:Inspector:
Site Name:Risk:
Address:
County:Region:
N W
Site/Facility Information Checklist:
Operating facility?:Yes No Facility No.:
Valid UST Permit?:Yes No
Number of USTs:
Number of ASTs:
Evidence of a spill or leak (describe):
Evidence of Free Product (describe):
Water Supply Well(s): Yes No ft.
WSW GPS Coordinates:
N W
Remediation System(s) Information:
System Condition:
Well Condtion:
Operating Upon Arrival:
On-Site Contact:
Name of RP:Company:
Name of Consultant:Company:
Other Representatives:Company:
North Carolina Deparment of Environmental Quality
Division of Waste Management
UST Section, Corrective Action Branch (CAB)
Complaint or Inspection Report (Circle One)
Distance to source:
GPS Coordinates:
Permit Expiration Date:
North Carolina Deparment of Environmental Quality
Division of Waste Management
UST Section, Corrective Action Branch (CAB)
Pictures Descriptions:
Photo 1:
Photo 2:
Photo 3:
Photo 4:
Time Spent on site:
Comments:
Figure:Figure
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