LPC Number IEMA Number Site Name Street City Zip Code County

Incident Number: LPC Number: IEMA Date:
Regulated By: Products: Project Manager:
20 Day Rpt: 45 Day Rpt: Heating Oil Date:
NFR Date: Pre-74 Date: Non-LUST Date:
NFR Recorded: NFR Voided: NFR Rescission:
Date Description
Event Description Date Response Due Decision Mailed
Barriers
Buildings/Structure
Pavement
Soil
Barriers Other
Institutional Controls
Groundwater Use Restriction
Ordinance
Industrial/Commmercial Land Use Restriction
Worker Caution
Other
ELUC
Groundwater Use Restriction
Industrial/Commmercial Land Use Restriction
Engineered Barrier
Worker Caution
Soil Handling
Other
Highway Authority Agreements
Highway Authority
Highway Authority Memo
Bills Received Status Code Amount Requested Amount Paid Voucher Date Deductible
Name: Contact:
Address: