Spill - Template

Mercy Medical Center - North Iowa West Campus - 310995325

910 N EISENHOWER AVE Mason City, IA 50401

Cerro Gordo County

FO 2

Site Name:

Address:

City:

County:

State:

Zip:

Directions:

Section:

Tier:

Range:

Long:

Lat:

Spill Number:

042312-JBV-1420

Spill Location:

43.155570, -93.264290

Spill County:

Cerro Gordo

FO 2

Incident Report

Received:

Received By:

Discovered:

Assigned To:

Reported By:

Anonymous

DNR Observation

Individual

Company:

Name:

Title:

Phone:

Email:

Incident Information:

Sec:
Tier:
Range:
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
MERCY MEDICAL CENTER-NORTH IOWA	UST	Owner
HAL HUDSON	UST	Public Contact
JON LOHRBACH	UST	Legal Operator
MERCY MEDICAL CENTER-NORTH IOWA	UST	Owner
MERCYONE NORTH IOWA MEDICAL CENTER	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
Mercy Medical Center West Campus (042312-JBV-1420) Oil from Elevator system - Memo.pdf	Report	04/27/2012	2012-4-27 Spill Memo for Oil Under Floor DLM
Mercy Medical Center West Campus (042312-JBV-1420) 30 day report from Mercy.pdf	Report	04/27/2012	2012-5-4 30 Day Report from Mercy

File Name	File Type	File Date	Note

Comments

Date	Comment	Commenter
4/27/2012	Shut down the elevator. Oil is somewhere under the floor. No external sign of oil. No wells or tile line in the area. Per Jeff Vansteenburg	LORI RATTAY

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

Mercy Medical Center - North Iowa West Campus - 310995325

910 N EISENHOWER AVE Mason City, IA 50401

Cerro Gordo County

FO 2

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Facility Note

Incident Report

Responsible Party

Material Information

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Compliance Tracking

Possible Facility

Public Water Supply: Surface Water