Site Assessment Results

Facility Number
Owner - New Information Owner Name Address Contact Person Phone Number	Facility - New Information Facility Name Address County Contact Person Phone Number

	Tank #	Capacity in Gallons	Product	Date Last Used	Status	Regulated Status	Date Removed/Abandoned

Purpose of the Site Assessment: Permit Number:

Results: Date Release Reported: IEMA #:

Remarks:

Site Plan

Attach the Site Plan file that shows the location of the tanks and each sample collected.

Summary Table of Lab Results

Attach the Summary Table of Lab Results file from the accredited laboratory.

Laboratory Result Report

Attach the Laboratory Result Report files from the accredited lab for the specific indicator contaminants.

Document name	Last Uploaded	Attachment

Miscellaneous Files

Attach any additional files that support the findings of the site assessment.

Document name	Last Uploaded	Attachment

Please Note: 41 Ill. Adm. Code 178.100 states the following:

"CONFIRMED RELEASE" means a release that has been confirmed by soil sampling that produces lab results above lab reporting limits for the requisite indicator contaminants specified in the procedures found at 41 Ill. Adm. Code 176.330.

A confirmed release is not contingent upon whether detected contaminant concentrations exceed or fall below the Illinois Environmental Protection Agency (IEPA) Tier 1 corrective action objectives. All analytical results that exceed laboratory reporting limits shall be reported immediately to the Illinois Emergency Management Agency (IEMA), irrespective of concentration or comparison to Tier 1 standards.

Notification to IEMA shall be made immediately by contacting:

1‑800‑782‑7860 (within Illinois), or
217‑782‑7860 (outside Illinois).

Failure to comply with the mandatory reporting requirements described herein will result in the issuance of a Notice of Violation for failure to report a release, as required under applicable Illinois statutes and regulations.

Under the penalties as provided by law pursuant to Section 1-109 of the Code of Civil Procedure, the undersigned certifies that the statements set forth in this instrument are true and correct, except as to matters stated to be on information and belief and as to such matters the undersigned certifies as aforesaid that he/she verily believes the same to be true.

By checking this box, I certify that the sampling done herein complies with all requirements for the number and location of sampling pursuant to 35 Ill. Adm. Code 734.210 and, for any soil borings, with 35 Ill. Adm. Code 734.425 and 734.435, as incorporated into the rules and regulations of the Office of the State Fire Marshal as required by 176.330(a)&(b).

Name:

Title:

License #: required

Expiration Date:

Company:

Phone Number:

Email:

Verify Email: