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: Results:

Permit Number

Date Release Reported: IEMA #:

Remarks:

Site sampling analysis reports

Document name	Last Uploaded	Attachment

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: