OKLAHOMA CORPORATION COMMISSION
PETROLEUM STORAGE TANK DIVISION
Public Participation Report
PSTD Reviewer ______Approve [ ] Deny [ ] Date ______
1. CASE NUMBER Submitted to (PSTD P.E.A.):
FACILITY NUMBER To Fulfill Purchase Order:
2. Facility Name
Contact Person/Phone No.
Street Address, City, County , ,
3. Owner/Operator’s Signature______Date ______
By signing above the Owner/Operator affirms that they have read this report.
Owner/Operator
Contact Person/Phone No.
Address, City, State, Zip , ,
4. Consultant’s Verification Signature ______Date ______
Consultant and Firm
Phone Numbers: Voice: Fax: Pager/Cell:
E-Mail Address:
PSTD License Number: Expiration Date:
Consulting Firm Principal Signature______
5. This report is being submitted:
Subsequent to an emergency situation
With the ORBCA Tier 1/1A Report recommending case closure
With the ORBCA Tier 2 Report
With the final Remediation Plan
With a Request for Case Closure
Subsequent to OCC/PSTD’s approval of
With a Case Closure Report
6. Does the communication(s) include information about the release and the availability of this information at the Oklahoma Corporation Commission (OCC)?
Yes No
7. If applicable, does the communication(s) include information that a remediation plan awaiting approval and available for inspection at the OCC?
Yes No N/A
8. If applicable, does the communication(s) include information about the case awaiting closure based upon risk assessment?
Yes No N/A
9. If applicable, does the communication(s) include information about the termination of an approved remediation plan that fails to meet established cleanup levels?
Yes No N/A
10. Copy the communication that described the level and type of risk that this release presents to the receptor. Be site- and receptor-specific. This should include the pathway and the phase (dissolved, vapor, etc.) of the contaminant. This notification should inform the property owner that they are responsible for passing this information on to any lessees or tenants of the property.
11. If applicable, copy the communication that describes how remediating this petroleum release will impact the receptor. Be site- and receptor-specific. Examples might include hauling impacted soil, vapors from remediation systems and improved property values.
12. These additional forms of communication may be used when direct notification by certified mail to all property owners affected by the release has been unsuccessful or insufficient.
Public notice printed in local newspaper of record. Attach copy of notice and newspaper affidavit.
Newspaper(s):
Dates printed:
Sign on site. Verify with a photograph that clearly and legibly shows the wording of the sign. A second photograph should be taken from a nearby public road that shows the sign’s placement on the site.
Size of sign (height and width):
Height of lettering:
Date sign was erected:
Other, Explain:
PUBLIC IDENTIFICATION
(Receptor) / Address / Postal ID / ORBCA-Identified
Pathway
Name of Public
(Receptor) / Address / Postal ID / ORBCA-Identified
Pathway
Add additional pages as required.
4
Public Participation Report
Revised October 2005