Fillable Generic Remedy Heating Oil Cleanup Report Form (Page 2 of 3) in pdf

Initial Abatement Information (check √ the appropriate answer)

3. ____ Yes ____ No ____ NA As much heating oil and sludge as possible has been removed from the tank.

Gallons removed:___________

Name of oil ____ recycling or ____ disposal company (check ■ one):_________________________________

4. ____ Yes ____ No

Hazards posed by contaminated soil that has been excavated or exposed have been remedied.

Note: Contaminated soil cannot be stored on-site for more than 30 days without a permit from DEQ.

5. ____ Yes ____ No

Free product has been observed in the ____ tank pit and/or ____ groundwater(Check √ any that apply).

Note: Any free product observed must be removed and properly treated/disposed. Use of the Generic

Remedy for Heating Oil Tank Releases is not appropriate if free product is present.

6. ____ Yes ____ No

Groundwater has been encountered during tank decommissioning or cleanup actions taken to-date.

Note: DEQ must be notified immediately when groundwater is encountered at any time.

____ Yes ____ No

Water in the tank excavation was encountered and pumped out, but did not recharge after 24 hours.

Use of the Generic Remedy for Heating Oil Tank Releases is not appropriate if water recharges into

the excavation 24-hours after initial pumping.

How was the release initially discovered? (Check ■ any boxes that are correct)

During tank decommissioning

During a site assessment not associated with tank decommissioning (e.g. for property transaction, etc.)

Other. Describe:________________________________________________________________

What observations were made about the tank condition when it was removed from the excavation or decommissioned in-

place? Describe:______________________________________________________________________________

________________________________________________________________________________________________

How much contaminated soil was removed? ___________ cubic yards What was done with the contaminated soil?

(Check ■ any boxes that apply)

Disposed of at:_______________________________________________________ (name of disposal company)

Treated off-site at:____________________________________________________ (name of treatment company)

Treated on-site. ATTACH copy of Solid Waste Letter of Authorization permit approved by DEQ.

Yes

No On-site treatment of contaminated soil is complete. (check ■ one)

10.

How was the cleanup conducted? Describe actions taken during cleanup and note any unusual circumstances:

____________________________________________________________________________________________________

________________________________________________________________________________________

Note highest TPH soil sample result prior to any excavation of soil:_________________ mg/kg TPH-Dx

11.

12.

The following information must be ATTACHED as part of this report (clearly label each attachment as listed below):

Attachment

Label ID

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 samples collected and identifies each

location and sample with an unique sample identification code. An additional cross-section diagram may be necessary to

clearly show sample locations at-depth.

Copies of chain-of-custody forms for all soil 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. Include data

for all samples, even if data is not used in summary (question #13).

May 2015

Page 2 of 3

hot gen rem cleanup rpt 5-12-15

Generic Remedy Heating Oil Cleanup Report Form Page 2

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