DEQ Utah DERR/LUST Release and Initial "RBCA"
Site Assessment Report		 Form
DEQ_Spills
Release Site
       
     
Name:  *Date Received:
Date Picker
*Address:
ReleaseDate: Date Picker
*Zip:
Date Confirmed: Date Picker
 *City:
Owner First / Last :   
Phone:   Owner Phone:   
       
Comments
250 Character Limit:
   
Reporting Party Information
       
*Your Name:   *Product Released:
*Your Phone:   *Cause of Release:
Your Company Name:   *Source of Release:
Above Ground Tank:   *Determination:
       
Initial Abatement / Corrective Action  
       
Performed?    
 If Yes Explain
 (250 Character Limit):

Agencies Notified/On-Site  
       
LHD Fire Department:  
DEQ/DERR EPA:.
DEQ/DE Other: