- ^ ^ 

^ 

Stete of Oregon 

Department of 

Environmental 

Quafity 

OREGON DEPARTMENT QF ENVIRONMENTAL QUALITY 

UNDERGROUND STORAGE TANK PROGRAM 

OREGON SOIL MATRIX CLEANUP 

STUDY GUIDE ORDER FORM 

A Study Guide is available to help you prepare for the state specific 

Oregon Soil Matrix Cleanup Examination. If you wish to obtain a copy 

of this guide, please fill out this form and submit the required amount for 

each book ordered. 

The Study Guide will include the laws, rules and technical information 

that will be covered on the Soil Matrix Cleanup exam. Exams are given 

to test your knowledge ofthe current laws, safety practices and technical 

requirements ofthe specific license. 

For information on obtaining study materials for the Intemational Code Council's (ICC) National Examinations 

including UST Installation/Retrofit, UST Decommissioning, UST Tightness Testing, UST Cathodic Protection 

and UST System Operator Exams please contact the ICC Order Department at (800) 786-4452 or contact Steve 

Paiko at 503-229-6652, or via e-mail atpaiko.steven.i(a),deq.state.or. us . 

FOR DEQ USE ONLY 

DATE REC'D: 

AMOUNT REC'D: 

CHECK NO.: 

PICK UP: 

SENT: 

Please submit your completed 

Oregon Soil Matrix cleanup Study Guide form to: 

Department ofEnvironmental Quality 

Attention: Business Office 

811 SW 6th Avenue 

Portland, Oregon 97204 

Enter number of Study Guides desired in the box below. 

U 

Soil Matrix Cleanup 

Name: 

Address 

City, State & Zip 

Amount Remitted for Study Guide(s) (^ $18.00 ea. 

Phone: 

*Shipping and Handling charges @ $4.00 each Study Guide ordered = $_ 

Total remitted for Study Guides plus Shipping and Handling = $_ 

< 

*Notice: Shipping and handling charges do not apply to study guides picked up at 811 SW 6th 

venue on the 8th floor. 

or assistance or questions, please call (in Oregon) 1-800-742-7878, 

(outside Oregon) (503) 229-6652, or FAX (503) 229-6977. 

May 2007 Page 1 of 1 DEQ-06-LQ-020A 
I 
-^5^ ' ^ M 

DEQ 

stats of Oregon 

Department of 

Environmental 

Quality 

OREGON DEPARTMENT OF ENVIRONMENTAL QUALITY 

Underground Storage Tank Program 

Soi l Matri x Cleanu p 

SERVICE PROVIDER LICENSE APPLICATION 

For tinis license application to be valid the total fee, the list of UST cleanup projects completed and list of 

licensed supervisors working for the Service Provider must accompany it. Renewal applications must be 

submitted 30 days prior to expiration. You should receive your license from DEQ within one to two weeks 

from the date you submit the complete application. Note: There is a separate license required to perform 

heating oil tank services. 

Please return this application, fee and attachments to: 

Department of Environmental Quality 

Attention: Business Office 

811 SW. Sixth Avenue 

Portland, OR 97204 

(3)Questions? In Oregon, call 1-800-742-7878 

Outside Oregon, call 503-229-6652 / FAX: 503-229-6977 

FOR DEQ USE ONLY LIC SMC 

Date Rec'd.: 

Amount Rec'd.: $ 

Check No.: 

Effective March 10, 2008 th e non-refundable license fee is $600 for 24 months 

Check (•) the appropriate box below: This application is for 

QNe w License L i Renewal License No.:_ • • '• Expiration Date: ' 

1. SOIL MATRIX CLEANUP SERVICE PROVIDER INFORMATION 

FIRM PROVIDING UST CLEANUP SERVICES 

Legal Name^: 

Address: 

Citv, State: 

Zip Code: 

Telephone No.: 

Contact Person: 

E-Mail Address. ^ : 

CORPORATE HEADQUARTERS (If Different) 

Name: 

Address: 

Citv, State: 

ZiD Code: 

Telephone No. 

^pc i 

2. OREGON CONSTRUCTION CONTRACTOR LICENSE 

CB License Number: '^''f^0:^'V':'-'f^^^^ (if required for the type of work your firm performs) 

Check here if you are in the process of obtaining a Contractors License from the Oregon Construction 

Contractors Board (CCB). Call 503-229-6652 to provide the license number when complete. 

' As registered with the Oregon Corporation Division 

March 2008 Page 1 of 2 05-LQ-079C 
UST Soil Matrix Cleanup Service Provider License Application 

3. SUPERVISORS Provide the name and license number for each Soil Matrix Cleanup Supervisor your firm 

employs. A supervisor must be on site at specific times or stop work. Attach additional pages as needed. 

Supervisor Name: Soil Matrix Cleanup License Number: 

4. SERVICE AREA Areas of Oregon where your firm will provide services to the public. Check as many that apply 

or simply check Statewide. See map for definitions of DEQ regions. You must check at least one. 

Statewide | | 

Eastern j | 

Northwest 

Western 

NORTHWEST REGION: 

Clackamas, Clatsop, 

Columbia, Multnomah, 

Tillamook & Washington 

Counties 

WESTERN REGION: Benton, 

Coos, Curry, Douglas, Jackson, 

Josephine, Polk, Lane, Lincoln, 

Unn, Marion & Yamhill Counties 

EASTERN 

REGION: 

Baker, Crook, 

Deschutes, 

Gilliam, Grant, 

Hamey, 

Hood River, 

Jefferson, 

Klamath, Lake, 

Malheur, 

Mon'ow, 

Shemnan, 

Umatilla, 

Union, Wasco, 

Wheeler & 

Wallowa 

Counties 

5. EXPERIENCE Attach a summary of UST cleanup projects completed in Oregon during the last 12 months, if 

this is a new application, on a separate page, describe your company's experience in conducting UST cleanups. 

Check here if your company has networked on any cleanup projects during the last 12 months. • 

SAMPLE INFORMATION 

Company or Individual Name/Address 

Sample Company 

1515 SE Champion Way 

Portland, OR 97333 

Type of Project 

Soil Matrix Cleanup 

Date Completed 

October, 2000 

Oregon LUST File No. 

26-00-9999 

6. CERTIFICATION 

"/, (your name) •••' • . ; :; • , am the Chief Executive Officer (or legal 

equivalent) of (company name) • ^ , and do hereby certify that I have 

obtained a copy of the applicable laws and rules pertaining to the regulation of Underground 

Storage Tanks In the State of Oregon, and that I have read them and will direct the employees and 

principals of this company to perform the tank services rendered by this company In the manner 

that is consistent with their requirements." 

"By my signature below, I state that the Information contained In this application is true and 

complete to the best of my knowledge." 

Signature: 

Name: Wii 

Date: 

Title: 

(Must be ptincipal in the firm) 

Page 2 of 2 

^o^ 

• ^ 

DEQ 

Slate of Oregon 

Department of 

Environmental 

Quality 

OREGON DEPARTMENT OF ENVIRONMENTAL QUALITY 

Underground Storage Tank Program 

Soil Matrix Cleanup 

SUPERVISOR LICENSE APPLICATION 

Please return this application along with required fee and exam report to: 

Departnnent of Envlronnnental Quality 

ATTENTION: Business Office 

811 SW Sixth Avenue 

Portland, OR 97204 

(2)Questions? In Oregon call 1-800-742-7878 

Outside Oregon call (503) 229-6652 FAX (503) 229-6977 

Complete the following information: 

FOR DEQ USE ONLY LIC SMC 

Date Rec'd: 

Amount Rec'd: 

Check No.: 

APPLICANT INFORMATION 

YOURNAME: 

ADDRESS: 

CITY: • 

STATE & ZIP: 

TELEPHONENo. • 

E-MAIL ADDRESS: 

• 

EMPLOYER INFORMATION 

COMPA>JYNAME: 

ADDRESS: 

CITY: 

STATE&ZIP: 

TELEPHONENo. 

E-MAIL ADDRESS: 

Effective July 6, 2001 the non-refundable license fee is $150 for 24 months 

Check (•) the appropriate box below: This application is for 

New Renewal License No.: License Expiration Date: 

ATTACH the passing examination documentation for Oregon Soil Matrix Cleanup Supervisor 

Important Note: There is a separate application form and license fee for Heating Oil Tank Services 

and UST Services Supervisor licenses. 

Applicant Signature:. Date: 

For this license application to be valid it must be accompanied by the total fee and the passing score report 

J

ou received from the test administrator, LaserGrade or Pearson VUE (formerly Promissor). License 

pplications must be submitted to DEO within 30 days of passing the qualifying examination. Renewal 

applications must be submitted 30 days prior to expiration. You should receive your license from DEQ within 

one to two weeks from the date you submit the complete application. 

Please notify DEQ immediately of any address changes so you do not miss impoi-tant bulletins! 

January 2008 Page l of 1 DEQ-05-LQ-080B