Generic Remedy Heating Oil Cleanup Report Form Page 3
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1
2
3Copies of all receipts or permits related to the disposal of any ______ oil / sludge, ______ free product, ______ water
E
pumped from the excavation, ______ contaminated soil, and/or decommissioned ______ tank and ______ piping
(check ■ all that apply).
F
Any photographs taken at the time of the heating oil tank decommissioning and cleanup that depict major activities (e.g. tank
as it is removed to note presence or absence of pits or holes, contaminated soil handling, excavation, tank/excavation in
relation to home, unusual circumstances, etc.)
13.
Provide a summary of the concentrations measured in the FINAL round of soil samples from each sample location that clearly
show the extent and magnitude of the contamination.
Note: Write in the specific unit of measurement for each contaminant if different. Write in “N/A” if sample not analyzed for
TPH-Dx constituents. Use additional pages as necessary to report final summary results.
Sample
Location
TPH-Dx
Benzene
Ethylbenzene
Naphthalene
ID
ID
Conc.
Conc.
Conc.
Conc.
_____________
___________________
_______________ mg/kg
_______________ ppm _____________ ppm _____________ ppm
_____________
___________________
_______________ mg/kg
_______________ ppm _____________ ppm _____________ ppm
_____________
___________________
_______________ mg/kg
_______________ ppm _____________ ppm _____________ ppm
_____________
___________________
_______________ mg/kg
_______________ ppm _____________ ppm _____________ ppm
_____________
___________________
_______________ mg/kg
_______________ ppm _____________ ppm _____________ ppm
_____________
___________________
_______________ mg/kg
_______________ ppm _____________ ppm _____________ ppm
Final Report Checklist and Signature
All of the following boxes must be checked indicating that the action has been taken and/or procedures followed correctly.
Completing this information does not substitute for service provider checklist certification requirements in OAR Chapter 340,
Division 163. The person signing this report must ensure that this information is correct. “Guidance” refers to the Heating Oil Tank
Generic Remedy Guidance Document.
The cleanup project is for a release from a residential underground heating oil tank (a tank used primarily for single-family
dwelling purposes; OR
The cleanup project is for a commercial underground heating oil tank. On a separate attachment, describe why use of the
generic remedy for residential tanks is appropriate to use for the commercial tank.
A verbal report of the discovery of contamination from a leaking heating oil tank was made to the appropriate DEQ regional
office.
The underground tank was decommissioned following the procedures in Appendix 2 of the Guidance.
A site assessment was conducted and the magnitude and extent of the contamination was determined in accordance with the
procedures outlined in Appendix 3 of the Guidance.
All samples were collected in accordance with methods described in OAR 340-122-0345.
This project meets all of the Qualifying Criteria set forth in Section 2 of the Guidance.
This project meets Remedial Action Alternative 1 of the Guidance; OR
This project meets Remedial Action Alternative 2 of the Guidance.
“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:______________________________ ____ Licensed Cleanup Supervisor?
(please print)
(if yes, check √ box)
Signature:_______________________________________
Date:_________________
Supervisor License No.:____________________
Expiration Date:__________________
Licensed Heating Oil Tank
Service Provider Company:_________________________________
Company License Number:____________ Expiration Date:____________________
____ Yes ____ No Additional information is included. If yes, write in attachment label(s):___________________
(check √ one)
NOTE: If cleanup work and report documentation was conducted by the homeowner, on a separate sheet of paper, describe
how you learned how to perform the cleanup work.
May 2015
Page 3 of 3
hot gen rem cleanup rpt 5-12-15
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