Generic Remedy Heating Oil Cleanup Report Form
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3OREGON DEPARTMENT OF ENVIRONMENTAL QUALITY
Underground Storage Tank Program
H
O
T
S
EATING
IL
ANK
ERVICES
S
P
R
C
ERVICE
ROVIDER
EPORT
ERTIFICATION
G
R
H
O
C
R
F
ENERIC
EMEDY
EATING
IL
LEANUP
EPORT
ORM
Complete this report and submit it to the DEQ Northwest Regional Office (700 NE Multnomah St., Portland,
Oregon, 97232) within sixty (60) days from the date the release from a residential heating oil tank is cleaned up.
Completion of this report form satisfies the requirements of OAR 340-177-0055. Please read the Generic Remedy
Heating Oil Cleanup Report Form Instructions (DEQ-06-LQ-007) before completing this report.
General Information
Property Owner Name:_________________________________
DEQ Cleanup File No.:___________________
Property Address:_________________________________
City/State/Zip Code:_________________________________
County:__________________________
Owner Phone Number:___________________________________
Owner Mailing Address (if different):______________________________________________________
Name of Person Reporting Release:___________________________________________
Phone Number (if different from Owner):______________________________________
__________
Date the release was originally suspected ______ (e.g. water in tank) or
_______ confirmed (sight, smell, test). (check ■ one)
__________
Date the release was reported to DEQ. Name of DEQ person contacted:_________________________
Note: Confirmed releases must be reported within 72-hours by the service provider or the tank owner
who performed the work..
Date the tank was ____ removed or decommissioned ____ in-place (check √ one).
__________
Approximate size of tank:________________ gallons
If the tank was filled in-place, what type of inert fill material was used?____________________
How much?____________________________ ______ gallons ______ lbs. (check ■ one)
__________
Date cleanup started.
__________
Date cleanup completed.
__________
Approximate square footage of home on property where the release has occurred.
Initial Abatement Information (check √ or ■ the appropriate answer)
1. ____ Yes ____ No
A visual inspection of the release has been made and immediate actions taken to prevent any further
release or migration of heating oil into surrounding soils or groundwater.
2. ____ Yes ____ No
Any fire, explosion, and/or vapor hazards in soil or groundwater have been identified and mitigated.
Yes
No
NA
Monitoring for hazards has continued beyond initial identification.(check ■ one)
May 2015
Page 1 of 3
hot gen rem cleanup rpt 5-12-15
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