Ust Petroleum Release Form
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2(This Section for DEQ Use Only)
UST PETROLEUM RELEASE FORM
_____-_____-_______
LOG NUMBER:
____________________
RECEIVED BY:
-----------------INCIDENT INFORMATION--------------------------
DATE REPORTED: (today’s date) ______________________________ DATE DISCOVERED: _____________________________
SITE NAME: _______________________________________________________________________
SITE ADDRESS: ____________________________________________________________________
REGULATED UST & FAC NBR:________________
SITE CITY: ___________________________ ZIP: _________________
NON-REGULATED UST
SITE COUNTY: ____________________
PHONE: _____________________________
---------------------------------------------------------------------MAIL CONTACTS----------------------------------------------------------------------
REPORTED BY (required, person reporting this release to DEQ)
RESPONSIBLE PARTY (required, person responsible for remedial action)
NAME: ______________________________________________________
NAME: __________________________________________________________
COMPANY: __________________________________________________
COMPANY: ______________________________________________________
ADDRESS: ___________________________________________________
ADDRESS: _______________________________________________________
CITY: _________________________
ZIP: _________________________
CITY: ____________________________
ZIP: __________________________
STATE: ___________PHONE: ______________________________________
STATE: ______________PHONE: ____________________________________
EMAIL:_________________________________________________________
EMAIL:__________________________________________________________
INVOICE CONTACT (required, may be same as responsible party)
OTHER CONTACT(S) (Optional Information)
NAME: _________________________________________________________
NAME: __________________________________________________________
COMPANY: _____________________________________________________
COMPANY: ______________________________________________________
ADDRESS: ______________________________________________________
ADDRESS: _______________________________________________________
CITY: _____________________________ ZIP: _________________________
CITY: _________________________________ ZIP: ______________________
STATE: __________ PHONE: ______________________________
STATE: ___________ PHONE: __________________________
---------------------------------SITE ASSESSMENT (For Cause and Source Descriptions – See Next Page) -----------------------------------
DISCOVERY: (check one)
CAUSE: (check one)
SOURCE: (check one)
CONFIRMATION: (check one)
DECOMMISSIONING
OVERFILL
TANK
CONTRACTOR
ROUTINE MONITORING
SPILL
PIPING
RP REPORT
COMPLAINT
CORROSION
DISPENSER
STAFF DEQ
LEAK DETECTION
INSTALL PROBLEM
TURBINE PUMP
LAB DEQ
SITE ASSESSMENT
PHYSICAL/MECHANICAL DAMAGE
DELIVERY PROBLEM
LAB RP
TIGHTNESS TEST
OTHER
OTHER
LAB OTHER
OTHER
UNKNOWN
NOT REPORTED
OTHER
---------------------------------------------------------CONTAMINANTS (Select one or more)------------------------------------------------------
HEATING OIL
UNLEADED GASOLINE
LEADED GASOLINE
MISCELLANEOUS GASOLINE
DIESEL MOTOR FUEL
WASTE OIL
LUBRICANT
SOLVENT
OTHER PET. DIST.
CHEMICAL
MTBE
UNKNOWN
----------------------------------------------------------IMPACTED MEDIA (Select one or more)-----------------------------------------------------
DRINKING WATER
GROUNDWATER
SURFACE WATER
SOIL
VAPORS
FREE PRODUCT
------------------------------------------------SITE-MANAGEMENT (This Section Department Use Only)---------------------------------------
-
RELEASE STOPPED: __________________________________
FINAL REQUEST INVOICE DATE: __________________________________________
CLEANUP STARTED: _________________________________
NO FURTHER ACTION: ___________________________________________
NOTES/COMMENTS: ____________________________________________________________________________________________________________________
February 2012
11-LQ-050
Page 1 of 2
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