Spill - Template

Kum & Go #22 - 310610121

715 LANG CREEK AVE Grinnell, IA 50112

Poweshiek County

FO 5

Site Name:

Address:

City:

County:

State:

Zip:

Directions:

Section:

Tier:

Range:

Long:

Lat:

Spill Number:

110316-ACH-1617

Spill Location:

41.700000, -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
JD CARPENTER COMPANIES DBA HOME OIL	UST	Owner
KUM & GO LLC	UST	Owner
KUM & GO LC	UST	Legal Operator
DIVERDE REALTY INC	UST	Owner
KRAUSEWA LC	UST	Owner
KUM & GO LC DBA MAVERIK	UST	Legal Operator

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
12-09-2016\110316-ACH-1617.pdf	Report	11/04/2016	30 day

File Name	File Type	File Date	Note

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

Kum & Go #22 - 310610121

715 LANG CREEK AVE Grinnell, IA 50112

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