Underground Storage Tank Leak Corrective Action Report
Facility Information
Facility Name
Facility Address
City
State
ZIP Code
Facility ID Number
Owner/Operator Information
Owner/Operator Name
Contact Phone
Email Address
Release Information
Date Discovered
Discovery Method
Suspected Cause of Release
Substance Released
Estimated Quantity Released
Corrective Action Summary
Initial Actions Taken
Soil and/or Groundwater Assessment Results
Remedial Measures Implemented
Final Cleanup Actions and Results
Additional Information
Regulatory Agency Notification Date
Agency Contact Name
Comments or Attachments
Certification
Name
Title
Date