Form Eqp4000 - Leaking Underground Storage Tank Final Assessment Report Cover Sheet - Michigan Department Of Environmental Quality - Remediation And Redevelopment Division
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2MICHIGAN DEPARTMENT OF ENVIRONMENTAL QUALITY – REMEDIATION AND REDEVELOPMENT DIVISION
PO BOX 30426, LANSING, MI 48909-7926, Phone 517-284-5087, Fax 517-241-9581
LEAKING UNDERGROUND STORAGE TANK
FINAL ASSESSMENT REPORT COVER SHEET
NEW or
REVISED PER DEQ AUDIT
INSTRUCTIONS: COMPLETION OF THIS REPORT WITH ALL APPLICABLE INFORMATION IS MANDATORY pursuant to Part 213,
Section 324.21311a of the Leaking Underground Storage Tanks, of the Natural Resources and Environmental Protection Act, 1994 PA
451, as amended. Check one of the boxes above to indicate whether this is a new or revised submittal. Please provide the
completed Final Assessment Report with the associated Table of Contents, Form EQP4007, within 365-days of discovery of a release to
the appropriate RRD District Office.
SITE NAME:
FACILITY ID NUMBER:
STREET ADDRESS:
CITY:
ZIP:
COUNTY:
DATE(S) RELEASE(S) DISCOVERED:
CONFIRMED RELEASE NUMBER(S):
O/O NAME:
O/O EMAIL ADDRESS:
O/O STREET ADDRESS:
CITY:
STATE:
ZIP:
CONTACT PERSON:
PHONE:
FAX:
Permission is given for the Department of Environmental Quality to contact the Qualified Consultant:
YES
NO
FINAL ASSESSMENT REPORT INFORMATION: Answer All Questions (DO NOT LEAVE BLANKS)
1. Site Classification (1-4):
Previous Site Classification (1-4):
Type of RBCA Evaluation:
Tier I
Tier II
Tier III
2. Substance(s) released:
Gasoline
Diesel
Ethanol:
Other:
E-10
E-85
3. Has contamination migrated off-site above Tier 1 Residential RBSLs?
YES
NO
If YES, have off-site impacted parties been notified per Section 21309a(3) of Part 213?
YES
NO
4. Predominant groundwater flow direction:
Depth to groundwater:
5. Is mobile NAPL present: Currently?
YES
NO Previously?
YES
NO
If present, was it recovered?
YES
NO If recoverable, total gallons recovered since last reported:
to date:
6. Is migrating NAPL present:
YES
NO If yes, are actions being taken to stop the NAPL migration?
YES
NO
7. Since Last Report: cubic yards of soil remediated:
gallons of groundwater remediated:
Totals to date: cubic yards of soil remediated:
gallons of groundwater remediated:
8. Have toxic or explosive vapors been identified in any confined spaces (basement, sewer, etc.)?
YES
NO
9. Drinking water supply affected? Currently:
YES
NO
Previously:
YES
NO
Indicate type and # of wells affected:
Private #
Public Type II/III #
Municipal #
10. Has the release affected surface water or wetlands?
YES
NO
11. Estimated distance and direction from point of release to nearest: Private well:
Municipal well:
Surface water/wetland:
Is site within a wellhead protection zone?
YES
NO
12. Does the report include a request for: In –Situ injection?
YES
NO
DEQ approval for GSI compliance?
YES
NO
Groundwater not in an aquifer determination?
YES
NO
Institutional controls regarding off-site migration?
YES
NO
13. What type of corrective action is proposed for each contaminated media? (i.e., Air Sparge/Soil Vapor Extraction; Monitored Natural
Attenuation; Multi-phase Extraction; Excavation; Institutional Controls; etc.):
Page 1 of 2 EQP4000 (8/2013)
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