tier1investigationreport.docVIP

TIER 1 INVESTIGATION REPORT FORM Due within one year of the occurrence of any of the following: Receiving analytical results, which exceed action levels, while conducting investigations pursuant to paragraph (F)(3)(b) of OAC 1301:7-9-13; Electing to conduct corrective actions pursuant to paragraph (B)(2) of OAC 1301:7-9-13; Receiving analytical results, which exceed action levels, from a closure assessment conducted pursuant to paragraph (F) of OAC 1301:7-9-12; or Conducting corrective action activities pursuant to paragraph (B)(3) and (B)(4) of OAC 1301:7-9-13. OWNER/OPERATOR AND FACILITY DATA FACILITY INFORMATION: UST OWNER INFORMATION: COMPANY: COMPANY: ADDRESS: ADDRESS: CITY: CITY, STATE: COUNTY: ZIP CODE: ZIP CODE: CONTACT PERSON: LAT/LONG: PHONE: FACILITY ID #: UST OPERATOR INFORMATION: PROPERTY OWNER INFORMATION: COMPANY: COMPANY: ADDRESS: ADDRESS: CITY, STATE: CITY, STATE: ZIP: ZIP: CONTACT PERSON: CONTACT PERSON: PHONE: PHONE: UNDERGROUND STORAGE TANK (UST) SYSTEM DATA Tank # Date Installed Capacity Const. Material Tank Status Date Removed STATUS= OOS90 – Out of Service 90 days OOS90 – Out of Service 90 days RE - Replace R - Removed CIU - Currently In Use NA - Not Applicable CIS - Change in Service CIP - Closed in Place  SITE HISTORY AND VISUAL SITE EVALUATION (Include a description of the property, surrounding area, the date the release occurred, etc.) TIER 1 SOURCE INVESTIGATION POTENTIAL SOURCE(S): POTENTIAL SOURCE AREA(S): CHEMICALS OF CONCERN: SUBSURFACE INVESTIGATION: Soil borings installed during this investigation / date: previously installed soil borings / date: Monitoring wells installed during this investigation / date: previously installed monitoring wells / date:  SB/MW Install Date Location Installed With* Tot