Final Heating Oil Cleanup Report Form -State Of Oregon Department Of Environmental Quality
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1
2OREGON DEPARTMENT OF ENVIRONMENTAL QUALITY
Underground Storage Tank Program
H
O
T
S
EATING
IL
ANK
ERVICES
S
P
R
C
ERVICE
ROVIDER
EPORT
ERTIFICATION
FINAL H
O
C
R
F
EATING
IL
LEANUP
EPORT
ORM
Complete this FINAL report and submit it to the DEQ Northwest Regional Office (700 NE Multnomah St., Suite 600, Portland, OR
97232) as soon as possible, but within sixty (60) days from the date the release from a heating oil tank is cleaned up. If this report
cannot be submitted within the required time frame, contact DEQ (503-229-6170) to request an extension. OAR 340-177-0055(6)
Property Owner Name:_______________________________________
DEQ Cleanup File No.:___________________
Property Address:__________________________________________
City/State/Zip Code:_________________________________________
County:______________________________
Owner Phone Number:_______________________________________
Owner Mailing Address (if different):_____________________________________________________________________
Licensed Cleanup Service Provider Company:_______________________________________________________________
License Number:____________________
Expiration Date:___________________
__________
Date tank ____ removed or decommissioned ____ in-place. Approx. size of tank:________________ gallons
(check
√
all that apply and provide requested information)
U
U
If tank filled in-place:
What type of fill material was used?_____________________ How much?____________ gallons
Tank must be completely filled with inert solid material that is compacted and appropriate for site conditions.
If tank was removed, where was it recycled or disposed of?______________________________
What national code of practice was followed during decommissioning?
_______________________________________________________________________________
Describe how the tank was cleaned as thoroughly as possible to the maximum extent practicable:
_______________________________________________________________________________
_______________________________________________________________________________
How much product (oil) was removed? ________gal. Sludge? ________gal. Water? ________gal.
Where was the product/sludge/water recycled?________________ Disposed?_______________
__________
D ate cleanup started
.
___________
D ate cleanup completed
.
U
U
U
U
(Check
√
Yes or No)
U
U
____ Yes ____ No An INITIAL heating oil cleanup report form has already been submitted. If cleanup had not been started at
the time of the initial report, include a new initial report form that has the missing information completed.
____ Yes ____ No A narrative report is attached.
Complete the rest of this form. Be sure to sign and date page two after answering all questions.
1.
How was the release discovered? Describe:___________________________________________________________
2.
What initial measures were taken to control the spread of contamination? Describe:_____________________________
___________________________________________________________________________________________________
3.
What was observed when the tank was removed from the pit or decommissioned in-place? Describe:________________
____________________________________________________________________________________________________
August 2015
Page 1 of 2
hot final cleanup rpt 8-19-15
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