Spill - Template

MAVERIK #5070 - 310468345

1002 WEST ST Grinnell, IA 50112-1645

Poweshiek County

FO 5

Site Name:

Address:

City:

County:

State:

Zip:

Directions:

Section:

Tier:

Range:

Long:

Lat:

Spill Number:

091915-BJB-0826

Spill Location:

41.750000, -92.730000

Spill County:

Poweshiek

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
KUM & GO LC	UST	Owner
	UST	Public Contact
KUM & GO LC	UST	Legal Operator
KRAUSEWA LC	UST	Owner
MAVERIK GROUP LLC	UST	Legal Operator
PARK AVE PARTNERS LC	UST	Owner

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

Document Name	Type	File Date	Note
09-28-2015\091915-BJB-0826.pdf	Report		30 day written report

File Name	File Type	File Date	Note

Comments

Date	Comment	Commenter
9/21/2015	The facility cleaned up the spill and bagged off pump #7 for repair.	BRYAN BUNTON

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

MAVERIK #5070 - 310468345

1002 WEST ST Grinnell, IA 50112-1645

Poweshiek County

FO 5

Edit Facility Location

Generate Letter Template

Facility Note

Incident Report

Responsible Party

Material Information

Revise Open Text File

Public Water Suppliers

Compliance Tracking

Possible Facility

Public Water Supply: Surface Water