Final Heating Oil Cleanup Report Form -State Of Oregon Department Of Environmental Quality Page 2
Download a blank fillable Final Heating Oil Cleanup Report Form -State Of Oregon Department Of Environmental Quality in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Final Heating Oil Cleanup Report Form -State Of Oregon Department Of Environmental Quality with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2HOT Final Cleanup Report Form
4.
How much contaminated soil was removed? ___________ cubic yards ___________ tons
5.
What was done with the contaminated soil? (check
√
all that apply)
U
U
___ Disposed of at:___________________________________________________ (name of disposal company)
___ Treated off-site at:________________________________________________ (name of treatment company)
___ Treated on-site. ATTACH copy of Solid Waste Letter Authorization permit approved by DEQ.
____ Yes ____ No On-site treatment of contaminated soil is complete.
6.
What actions were taken during cleanup? Describe:____________________________________________________
_______________________________________________________________________________________________
(check
√
one)
U
U
7.
____ Yes ____ No Groundwater was encountered in the tank pit. If yes, ATTACH a separate summary of the data collected
and decision made by DEQ in accordance with OAR 340-122-0355(3).
8.
What is the
h ighest
TPH-Dx concentration measured?______________ mg/kg Sample ID No.__________________
U
U
9.
Provide a summary of the concentrations measured in the FINAL round of samples from each sample location.
Note: Write in the specific unit of measurement for each contaminant. Write in “N/A” if sample was not analyzed for a
contaminant. Use additional pages as necessary to summarize final results.
Sample
Sample
NWTPH-Dx
B T E or X
Any PAH’s
Media
ID
Location
Conc. (mg/kg)
Detected?
Detected?
Soil/Water
________
____________
____________
__Yes __No __N/A
__Yes __No __N/A
__________
________
____________
____________
__Yes __No __N/A
__Yes __No __N/A
__________
________
____________
____________
__Yes __No __N/A
__Yes __No __N/A
__________
________
____________
____________
__Yes __No __N/A
__Yes __No __N/A
__________
10. Check the type of remedial option selected for this cleanup project. Include any additional information necessary to
satisfy the specific remedial option report requirements. (check
√
only one)
U
U
___ Soil Matrix
OAR 340-177-0065(1)(a) Note: include matrix score sheet
___ Risk-Based
OAR 340-177-0065(1)(b)
___ Generic Remedy
OAR 340-177-0065(1)(c)
11. The following information should be
ATTACHED
as part of this report (
l ist the attachment number you assign for each one
) :
U
U
U
U
Attachment Number
_____
Site map, drawn roughly to scale, showing the location of all buildings on the property and on adjacent properties and
the location of the heating oil tank. Include distances in feet between objects.
_____
Sketch of the property that clearly shows the sample locations and depths of all soil and/or water samples collected and
identifies each location and sample with an unique sample identification code.
_____
Copies of chain-of-custody forms for all soil and water samples collected.
Note: Chain-of-custody forms should include the date, time, and location of each sample collected; the name and company
of the person collecting the samples; a description of how the samples were collected, stored, and shipped to the laboratory;
and note any problems encountered during the cleanup or sampling process that may have affected sample integrity. Forms
should clearly state the address of where samples were collected as a unique identifier.
_____
Copies of all laboratory data reports. Test methods used, including method reporting limits, must be included.
_____
Copies of all receipts or permits related to the disposal of any _____ oil / sludge, _____ free product, _____ contaminated
soil, and/or decommissioned _____ tank and _____ piping (check
√
all that apply).
U
U
_____
Photographs taken at the time of heating oil tank decommissioning and cleanup (not required, but helpful).
“By my signature below, I state that the information contained in this report is true and complete to the best of my knowledge.”
:
Name of person preparing report
______________________________________________
(please print)
Signature: _____________________________________ Date: _________________________
Supervisor License No.: ___________________________
Expiration Date: _________________
Clear All Entries
Print Form
Page 2 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Cg-21 - Out-of-state Cigarette Wholesaler's Monthly Tax Report Form - State Of Kansas
Financial
Form Mvh-trd-01.01 - Motor Vehicle Trade-in/trade-down Supplemental Reporting Form - State Of Nevada
Financial
Form Reg-d - Federal Identification Number Reporting Form - State Of New Jersey Division Of Taxation
Financial
Unlicensed Companies' Premium Tax Report Form - State Of New Hampshire Department Of Insurance - 2013
Financial
Related Categories
Parent category: Legal