Spill - Template

Iowa Methodist Medical Center - 310485602

1200 Pleasant St Des Moines, IA 50309

Polk County

FO 5

Site Name:

Address:

City:

County:

State:

Zip:

Directions:

Section:

Tier:

Range:

Long:

Lat:

Spill Number:

051410-AHB-1405

Spill Location:

41.590000, -93.630000

Spill County:

Polk

FO 5

Incident Report

Received:

Received By:

Discovered:

Assigned To:

Reported By:

Anonymous

DNR Observation

Individual

Company:

Name:

Title:

Phone:

Email:

Incident Information:

Sec:
Tier:
Range: W
Lat:
Long:

Responsible Party

Remove Facility

Is Individual

Unknown

Company:

Phone:

Email:

Address:

City:

State:

Zip:

Spill Contact

Name:

Title:

Phone:

Email:

Address:

City:

State:

Zip:

Name	Program	Type
IMMC/UNITY POINT HEALTH DSM	UST	Owner
GLENN LOVE	UST	Public Contact
TB CRAICI	UST	Legal Operator
WESTFORK SCHOOLS	Leaking UST	Public Contact
WESTFORK SCHOOLS	Leaking UST	Legally Responsible Entity

Material Information


Material: Medium: Quantity: Units:

Transportation:

Fish Kill:

Continuous Release:

Date of Investigation:

Incident Investigated:

Status:

Compliance Determination:

30 Day Report Not Expected

Transferred To Contaminated Sites:

Report

Attached Files/Reports

File Name	File Type	File Date	Note

Comments

Date	Comment	Commenter
5/14/2010	Absorb material on parking lot. Per Larry Hare, DM WRA, the water should be pumped and taken to the WRA for disposal rather than drain the water feature to the sanitary sewer.	KATHY LEE

Comment:

Public Water Suppliers

Name	Supply Type	PWS ID	Operator: Name / Phone Number	Contacted

Compliance Tracking

Action Type	Date	Completed Date	Comment	Delete

Multiple Results Found

Field Office Compliance - Spill

New Material

Iowa Methodist Medical Center - 310485602

1200 Pleasant St Des Moines, IA 50309

Polk County

FO 5

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Facility Note

Incident Report

Responsible Party

Material Information

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Public Water Suppliers

Compliance Tracking

Possible Facility

Public Water Supply: Surface Water