Spill - Template

Kwik Star #468 - 311256765

90 South Main Street Charles City, IA 50616

Floyd County

FO 2

Site Name:

Address:

City:

County:

State:

Zip:

Directions:

Section:

Tier:

Range:

Long:

Lat:

Spill Number:

071613-AHB-1057

Spill Location:

43.060000, -92.680000

Spill County:

Floyd

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: 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
KWIK TRIP INC	UST	Owner
Karl Semke	FO	Regulatory Contact
KOOB AUTOMOTIVE AND TOWING	Leaking UST	Public Contact
KOOB AUTOMOTIVE AND TOWING	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
7/17/2013	Fire and police were contacted and responded. EMA responded and contacted public works to open manhole and assist with absorbent placement. Kwik Star contractor in route to conduct cleanup.	ADAM BROUGHTON

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

Kwik Star #468 - 311256765

90 South Main Street Charles City, IA 50616

Floyd County

FO 2

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Public Water Supply: Surface Water