\ 

• 

DEQ 

State ofOregcsfi 

Oop^itmBxit cd 

Quattty 

UST PETROLEUM RELEASE FORM 

INCIDENT INFORMATIONDATE REPORTED: (today's date) 

(This Section for DEQ Use Only) 

LOG NUMBER: 

RECEIVED BY: 

DATE DISCOVERED: 

SITE NAME: 

SITE ADDRESS: 

SITE CITY: ZIP: 

REGULATED UST & FAC NBR:. 

NON-REGULATED UST 

SITE COUNTY: PHONE: 

REPORTED BY (required, person reporting this release to DEQ) 

NAME : ;^.^- ^ :::••/>.•;. • •"•' ' " •'• ':^!-^---'-

-MAIL CONTACTSRESPONSIBLE PARTY (required, person responsible for remedial action) 

NAME : ••' • -•'/-'" ' • •' •''• - • ' • •• '•• ^••" • • •'•' •• • • : 

COMPANY: 

ADDRESS: _ 

CITY: ZIP: 

COMPANY: 

ADDRESS: _ 

CITY: ZIP: 

STATE:. 

EMAIL: 

PHONE: STATE: 

EMAIL: 

PHONE: 

INVOICE CONTACT (required, may be same as responsible party) 

NAME: 

OTHER CONTACT(S) (Optional Information) 

NAME: •':• - •'• • • 

hMPANY: 

ADDRESS: _ 

CITY: ZIP: 

COMPANY: 

ADDRESS: _ 

CITY: ZIP: 

STATE: PHONE: STATE: PHONE: 

-SITE ASSESSMENT (For Cause and Source Descriptions - See Next Page) 

DISCOVERY: (check one) CAUSE: (check one) 

DECOMMISSIONING • OVERFILL 

ROUTINEMONITORING • SPILL 

COMPLAINT • CORROSION 

LEAK DETECTION • INSTALL PROBLEM 

SITE ASSESSMENT • PHYSICAL/MECHANICAL DAMAGE 

TIGHTNESS TEST JZ] OTHER 

OTHER • UNKNOWN 

SOURCE: (check one) 

• TANK 

• PIPING 

• DISPENSER 

• TURBINE PUMP 

• DELIVERY PROBLEM 

• OTHER 

CONFIRMATION: (check one) 

• CONTRACTOR 

• RP REPORT 

• STAFF DEQ 

• LAB DEQ 

• LABRP 

• LAB OTHER 

• OTHER 

• HEATING OIL • UNLEADED GASOLINE 

• DIESEL MOTOR FUEL • WASTE OIL 

• OTHER PET. DIST. • CHEMICAL 

-CONTAMINANTS (Select one or more) 

• LEADED GASOLINE 

• LUBRICANT 

• MTBE 

• MISCELLANEOUS GASOLINE 

• SOLVENT 

• UNKNOWN 

p ~ | DRINKING WATER GROUNDWATER 

IMPACTED MEDIA (Sielect one or more) 

SURFACE WATER SOIL VAPORS FREE PRODUCT 

-SITE-MANAGEMENT (This Section Department Use Only)-

RELEASE STOPPED: _ 

ANUP STARTED: 

NQTES/COMMENTS: 

» 

FINAL REQUEST INVOICE DATE: 

NO FURTHER ACTION: 

May2007 Pagel of2 DEQ-05-LQ-091A 
X 

CAUSE OF RELEASE DESCRIPTIONS y 

Overfill - Use this cause when an overfill occurs. For example, overfills may occur from the fill 

pipe at the tank or when the nozzle fails to shut off at the dispenser. 

Spill - Use this cause when a spill occurs. For example, spills may occur when the delivery hose 

is disconnected from the fill pipe ofthe tank or when the nozzle is removed from the vehicle at 

the dispenser. 

Corrosion - Use this cause when a metal tank, piping or other component has a release due to 

corrosion (for steel, corrosion takes the form of rust). This is a specific type of physical or 

mechanical damage. 

Installation Problem - Use this cause when the problem is determined to have occurred 

specifically because the underground storage tank system was not installed properly. Note that 

these problems may be difficult to determine. 

Physical or Mechanical Damage - Use this cause for all types of physical or mechanical 

damage except corrosion as described above. Some examples of physical or mechanical damage 

include a puncture ofthe tank or piping, loose fittings, broken components and components that 

have changed dimension (for example, elongation or swelling). 

Other - Use this option when the cause is known but does not fit into one ofthe above 

categories. For example, releases from vent lines, vapor recovery lines and fill lines would be 

included in this category. 

Unknown - Use this option only when the cause is notknowTi. 

SOURCE OF RELEASE DESCRIPTIONS 

Tank - This term means the tank that stores the product and is part ofthe underground storage 

tank system. 

Piping - This term means the piping and connectors running from the tank or submersible 

turbine pump to the dispenser or other end-use equipment. It does not include vent, vapor 

recovery or fill lines. 

Dispenser - This term includes the dispenser and equipment used to connect the dispenser to the 

piping. For example, a release from a suction pump or components above the shear valve would 

be considered a release from the dispenser. 

Turbine Pump (STP) - This term includes the submersible turbine pump head (typically 

located in the tank sump), the line leak detector, and the piping that connects the submersible 

turbine pump to the tank. 

Delivery Problem - This term identifies releases that occur during product delivery to the tank. 

Typical causes associated with this source are spills and overfills. 

Other - Use this option when the release source does not fit into one ofthe above categories. 

For example, releases from vent lines, vapor recovery lines and fill lines would be included in this 

category. > . 

May2007 Page 2 of 2 DEQ-05-LQ-091A 
r 4|tAHiy'P|-'* ,.&H,"iJ«!l»«flWr-^,l?VW*-TrV*!Wf'V-.-.r"S«.IJl«-.! 
OREGON DEPARTMENT OF ENVIRONMENTAL QUALITY PA 

DEQ 

UNDERGROUND STORAGE TANK PROGRAM 

statsofomgon Cost Recovery Agreement 

Department of 

Environmental 

Quality 

This document serves as an agreement between the undersigned (hereinafter "you") and 

the Department of Environmental Quality (DEQ) regarding DEQ review and oversight of 

the investigation and/or cleanup of petroleum (hazardous substances) at the property 

located at: 

Facilit y Name : •'--'' ' -. • • •' • •' • • • - • • ' 

Address: ' ^__ 

USTCNo.: 

DEQ agrees to review environmental documents submitted by you or on your behalf 

regarding the investigation and/or cleanup ofthe above-referenced site. Additional details 

regarding DEQ oversight will be established upon review ofthe initial site data. 

DEQ requires that persons requesting DEQ review and oversight of investigation and 

cleanup activities agree to the terms of this cost recovery agreement and pay project 

oversight costs. 

DEQ project oversight costs will include direct costs and indirect costs. Direct costs 

include site-specific expenses and legal costs. Indirect costs are those general 

management and support costs of the DEQ, including the Land Quality Division (LQ), 

allocable to DEQ oversight of this agreement and not charged as direct, site-specific 

costs. Indirect charges are based on a percentage of direct personal services costs. Review 

and oversight costs shall not include any unreasonable costs or costs not otherwise 

recoverable by DEQ under ORS 465.255. 

DEQ costs are due within thirty (30) days of issuance of the monthly statement, by a 

check made payable to the "Department of Environmental Quality". Nine percent 

interest shall be charged on past due accounts. 

Electing not to enter into this agreement does not release you from any responsibility that 

you might have for any reporting requirements, investigation and/or cleanup of petroleum 

(hazardous substances) at the above referenced facility. This does not preclude the DEQ 

from conducting audits or inspections of all or portions of the investigation and cleanup 

activities associated with this facility; Enforcement action may be initiated if any 

violation of Oregon Administrative Rules (OARs) or Oregon Revised Statutes (ORSs) is 

found. 

January 2008 Page 1 of 2 05-LQ-086A 
Either DEQ or you may terminate this agreement by giving 15 days advance written 

notice to the other. Only those costs incurred or obligated by DEQ prior to the effective 

date of any termination of the agreement shall be recoverable under this agreement. 

Temiination of this agreement will not affect any other right DEQ may have for recovery 

of costs under any applicable law. 

You will hold DEQ harmless for any claims (including but not limited to claims of 

property damage or persorial injury) arising from DEQ review and/or oversight activities 

under this agreement. 

This agreement is not and shall not be construed to be an admission by you of any 

liability under ORS 465.255 or any other law or as a waiver by you of any defense to 

such liability. This agreement is not and shall not be construed to be a waiver, release, or 

settlement of claims that DEQ may have against you or any other responsible person nor 

is this agreement a waiver of any enforcement authority that DEQ may have. 

The DEQ Tanks Program will be responsible for the review and oversight of the 

investigation and cleanup activities associated with the property. Please refer all sitespecific inquiries to the UST Regional Offices in Northwest Region - Portland, Westem 

Region - Salem and Eugene and Eastem Region - The Dalles. For locations and phone 

numbers of the regional offices, please see the UST Regional Office list at 

http://vyvyw.deq.state.or.us/about/locations.htm 

All inquiries regarding cost recovery and/or invoices should be directed to Dawn Ismerio 

at 503-229-5812. 

If the terms of this agreement are acceptable, please have it executed by an authorized 

officer in the space provided below. In order to more effectively schedule your project, 

please retum this agreement within 30 days of receipt to the regional office responsible 

for vour site. 

Accepted and agreed to this ' day of . 20 

B y : • " ' • ' •- - • - • - • ••^ : ' • • - -• •• 

Title: 

Please provide the following information as to where the invoices should be sent. 

Individual Name: 

Title: 

Company Name: 

Mail Address: 

City, State, Zip:_ 

Phone Number: 

January 2008 Page 2 of 2 05-LQ-086A 

^^o^ 

DEQ 

state of Oregon 

Depattn^ntof 

EnvtKinn»ntal 

QualHy 

OREGON DEPARTMENT OF ENVIRONMENTAL QUALITY 

UNDERGROUND STORAGE TANK PROGRAM 

Initial (Twenty Day) Report Form for UST Cleanup Projects 

This report is due twenty (20) days from tlie date ofthe release. 

DEQ USTC File No.. 

DEQ Facility ID No.. 

Site Name: 

Site Address: 

INITIAL CLEANUP INFORMATION 

(1) Type of contamination (check V all that apply): 

[ Gasoline \ [Diesel _ _ Waste Oil 

I Other (specify) " : • ' ' ^' '^ 

Heating Oil, 

(2) Estimate quantity of release (based on information known to date - • select only one): 

( 2) <100 gal. Q ) 100-499 gal. Q ) 500-999 gal. Q 1,000-5,000 gal. Q >5,000 gal. 

SITE INFORMATION (check V yes or V no) 

Y I I N Did any water enter the excavation? If yes, please describe and identify the depth to 

groundwater in feet below ground surface: • ''• '•• ' : • 

(3) 

(4) I I Y I——I N Was a sheen or odor observed on any water in the excavation? 

Note: If groundwater is encountered, soil samples from the soil/water interface must be collected and analyzed 

for BTEX and by the appropriate TPH method. 

At sites where diesel or other non-gasoline products have been released, the water may also have to be 

screened or tested for polynuclear aromatic hydrocarbons (PAHs). Please refer to OAR 340-122-0218. 

(5) I I Y I—I N Was water pumped from the excavation? 

I I Y I I N If yes, did groundwater recharge within 24 hours after pumping? 

Please describe the pumping procedure and disposal option selected for the purged excavation water: 

(6) I I Y I——I N Were any water samples collected from the excavation? If yes, please describe: 

(7) N Have any soil and/or water sample results been received at this time? 

If so, please attach any lab reports. 

January 2008 Page 1 of 4 05-LQ-089A 
Initial (Twenty Day) Report Form for UST Cleanup Projects 

IF GROUNDWATER HAS BEEN ENCOUNTERED, PLEASE ANSWER QUESTIONS #8-13, BELOW. 

IF NO WATER HAS BEEN ENCOUNTERED, PLEASE SKIP TO QUESTION #14 

(8) What are the known uses of groundwater within a 500-foot radius of the release site (check V all that apply)? 

non-use industrial | [ agricultural drinking supply , 

(9) If groundwater in this area is being used as-a drinking water supply, please check V the type and size of 

population served by the supply: 

Community (community well used for drinking water year round - • select only one) 

size: C ^ <1,000 people C ^ 1,000 - 5,000 people C ^ >5,000 people 

Intermittent use (public water used for drinking water only on a part-time basis- • select only one) 

size: (_J <50 people ^J ) 50 - 300 people ( ^ > 300 people 

[ _| Private wells (individual private well or wells used for drinking water - • select only one) 

size: rj<1 0 people (/ j 10-25 people \/ j >25 people 

(10) I I Y I I N Is there any evidence this water supply has been or is likely to be impacted from the 

petroleum product release? If yes, estimate how difficult it would be to replace the 

•

existing supply: 

bottled water is the only alternative • on-site water treatment; bulk water delivery; new wells are available 

I 'able to connect to existing water supply 

I Ifin not know what alternatives would be available 

(11) I I Y I _J N Are/were vapors present in on-site or nearby buildings? If yes: 

l 

A. Are you monitoring and/or mitigating any potential fire and safety hazards posed by vapors 

and free product? Explain: "^ : . 

(12) 

(13) 

B. Estimate the number of people potentially affected by vapors - • select only one: 

^ ] ^ 1-2 people r j 3-10 people (_J) >10 people 

Y N Are vapors or is petroleum contamination present in the utility corridors? 

If yes, please explain: 

Y N Are natural areas located within 1/4 mile ofthe site? If so, please describe types (parks. 

rivers, wetlands, sensitive habitats, etc.) and proximity: 

(14) Y N If groundwater was not encountered in the excavation, do you believe that this cleanup 

project can be conducted under the requirements for an UST Cleanup Matrix site? If yes, then 

refer to OAR 340-122-0305 through 0360. 

January 2008 Page 2 of 4 05-LQ-089A 
Initial (Twenty Day) Report Form for LIST Cleanup Projects 

AREA/SITE CONDITIONS: 

(15) Mean annual rainfall: f ^ <20 inches C I 20-45 inches r^ l >45 inches 

(16) Soil type(s) ofthe naturally occurring soils, not the backfill around the tank- • select only one: 

\ ^ clays, compact tills, shales, and unfractured metamorphic and igneous rocks 

G

sandy loams, loamy sands, silty clays, clay loams, moderately permeable limestone, dolomite, 

sandstones, moderately fractured igneous and metamorphic rock 

o fine and silty sands, sands and gravels, highly fractured igneous and metamorphic rock, 

permeable basalts and lavas, karst limestones and dolomites 

SOIL MANAGEMENT 

f soil sample resi 

• YDN 

(17) If soil sample results have been received: 

Will the level of contamination detected require removal of contaminated soil for 

treatment or disposal? 

(18) All contaminated soil temporarily stockpiled on-site prior to treatment or disposal must be contained within 

a bermed area, kept covered, and the entire area secured to prevent unauthorized access by the public. If 

you haven't done this, please explain why: 

Note: It is a violation to stockpile petroleum contaminated soil (PCS) on-site for greater than 30 days 

without a DEQ Solid Waste Letter Authorization (SWLA) Permit. 

(19) If contaminated soil is currently stockpiled on-site, please indicate when disposal will occur or when 

treatment will,begin: .: •' • • • • • • 

(20) Estimated volume of contaminated soil (specify tons or cubic yards): 

(21) Intended disposition of soils (please • select only one): 

r ^ On-site/off-site treatment. Solid Waste Letter Authorization Permit Application attached. 

G Thermal treatment off-site at an authorized facility. 

Facility name: 

Landfill disposal. 

Name of Landfill: 

Note: Please attach additional information as necessary to explain any unusual circumstances 

associated with this project. 

January 2008 Page 3 of 4 05-LQ-089A 
Initial (Twenty Day) Report Form for UST Cleanup Projects 

This initial report is intended to provide the Department with the basic initial information about activities associated 

with the release. Future reports should provide a more detailed and complete picture ofthe cleanup project. 

Please be aware that a DEQ permit/authorization is required for the following activities: 

1) Soil aeration, bioremediation (on-site or off-site), or on-site thermal treatment. 

2) Water discharges to a stream/stonn drain from the excavation or treatment tank. 

If these activities will be included in your cleanup project, contact the regional DEQ office for the appropriate 

application forms, information on permit fees and guidance documents. 

THIS REPORT WAS PREPARED BY: 

Individual : '^ •" '''•^•- '• ' • • ' - ^ ' • • • • •• •- •: - Date : 

Company : -•• :•"'•• ' ' • - •' Phone: 

Address : "y:-^ -^ • • : •""--'• - •- -' . '••' . • •• ..-.• • • 

City : - ••: '•- • • : - • •-•-"•••. • . :.- •:• : • : : • Stat e . : Zip . 

1. Please return this form to the regional office in which the site is located. 

If you have questions, call the contact person in your regional ofiice. 

2. For all tanks, except heating oil tanks, you must submit an UST Decommissioning 

Checklist and Site Assessment Report to the appropriate regional ofiice 

within 30 days of the UST decommissioning. 

Failure to do so can result in delays to your project and 

may result in continued billing for the annual tank permit fees. 

3. Addresses and phone numbers for the regional offices can be found in the 

UST Cleanup Manual or viewed and downloaded from this DEQ Webpage: 

http://www.deq.state.or.us/about/locations.htm 

4. Copies of the UST Cleanup Manual and other UST program forms and checkUsts 

can be viewed and downloaded from DEQ's Website: 

http://www.deq.state.or.us/lq/tanks/ust/index.htm 

or in the Portland area by calling Steve Paiko at 503-229-6652 

or outside the Portland area leaving a message on the 

UST Help Lme (toll-free in Oregon) at 1-800-742-7878 

KEEP A COPY OF TfflS REPORT FOR YOUR FACILITY RECORDS 

V 

January 2008 Page 4 of 4 05-LQ-089A 
i 
^ < ^ 

^ 

DEQ 

state of Oregon 

Department of 

Envfronmental 

Quafrty 

OREGON DEPARTMENT OF ENVIRONMENTAL QUALITY 

Underground Storage Tank Program 

SOIL MATRIX CHECKLIST AND 

SOIL MATRIX SCORESHEET 

D 

• 

• 

1. The release of petroleum has been reported to the DEQ (0220). 

2. The matrix score sheet has been completed for this site, unless the site is cleaned up to the most 

stringent cleanup level (0320). 

3. The required hydrocarbon identification test (NWTPH-HCID) has been performed (0335(3)), and, if 

detectable levels were found, the appropriate analytical method or methods have been used to measure the 

levels of contamination (0218). 

4. A sketch has been made of this site (0345(1)) which clearly shows: 

I I a. Thelocationofallbuildingsandotherkey features, both man-made and natural; 

I I b. The names ofadjacent streets and properties; 

I I c. The location of all excavations including those that were for the removal of tanks and 

associated piping as well as those that were strictly for the removal of contaminated soils; 

' I d. The location of all product storage tanks, lines and dispensers, including those that 

were decommissioned as well as those that remain on the site; and ( 

D All soil and water sample locations. 

5. If any contaminated soil exceeding matrix limits has been left on site, the reason for leaving this soil 

has been explained and the requirements of 0340(l)(f) and 0355(4) have been met. 

6. If water was present in the tank pit, the Department was notified, the water was pumped fi-om the pit, 

and the requirements of 0340(4) have been met. 

7. All soil and/or water samples have been collected, coded, stored and shipped as specified in the 

rules, and proper chain-of-custody forms have been filled out (0345). 

8. If a release from a waste oil tank was discovered, at least one sample has been analyzed by the 

methods specified in 0218(l)(b)(D). • / > 

9. If a tank was decommissioned in place, the Department gave prior approval for a site-specific 

sampling plan (0340(5)). 

10. A report has been prepared which includes a detailed description of everything that was 

observed and performed at the site, contains all of the infonnation required by the rules (0360), and presents 

findings and recommendations which are consistent with Department regulations. 

January 2008 Page 1 of 2 08-LQ-046 
SOIL MATRIX SCORE SHEET 

1. Depth to Groundwater 

< 9s fppt (]0^ 

25 - 50 feet (7) 

51-100 feet (4) 

> 100 feet (1) 

2. Mean Annual Precipitation 

> 45 inches (10) 

20 - 45 inches (4) 

< 20 inches (1) 

3. Native Soil Type 

Course sands, gravels (10) 

Silts, fine sands (5) 

Clays (1) 

4. Sensitivity of Uppermost 

Aquifer (10) 

Sole Source (7) 

Current Potable (4) 

Future Potable (1) 

Non-potable 

5. Potential Receptors 

Many, near (10) 

Medium - (5) 

Few, far (1) 

TOTAL SCORE 

MATRIX 

SCORE 

Level 1: >40pts. 

Level 2: 25-40pts. 

Level 3: <25pts. 

0 

Cleanup Level (ppm 1 PH) 

Gasoline 

40 

80 

130 

Diesel 

100 

500 

1000 

January 2008 Page 2 of2 08-LQ-046