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Stet e o f Orego n Departmen t

o f Environmenta l Quafit y 

## OREGO N DEPARTMEN TQ F ENVIRONMENTA L QUALIT Y

UNDERGROUN D STORAG E TAN KPROGRA M OREGO N SOI L MATRI X CLEANU P STUD YGUID E ORDE R FOR M AStudy Guid e i s availabl e t o hel p yo u prepar e for th e stat e specifi c Orego nSoi l Matri x Cleanu p Examination . I f yo u wis ht o obtai nacop y o f thi s guide , pleas e fil l ou t thi s for man dsubmi t

th e require damoun t

for eac hboo k

ordered . Th e Study Guid e wil l includ e th e laws , rule s an dtechnica l informatio n that wil l b e covere do nth e Soi l Matri x Cleanu p exam . Exam s are give n t o tes t you r knowledg e ofth e curren t laws , safet

y practice s an dtechnica l requirement s ofth e specifi c license . Fo r informatio no nobtainin g study material s for th e Intemationa l Cod e Council' s (ICC ) Nationa l Examination s includin g US T Installation/Retrofit , US T Decommissioning , US T Tightnes s Testing , US T Cathodi c Protectio n an dUS T Syste mOperato r Exam s pleas e contac t

th e IC C Orde r

Departmen t

a t (800 ) 786-445 2 or

contac t Stev e Paik o at 503-229-6652 , or

viae-mai l atpaiko.steven.i(a),deq.state.or . u s . FO RDE Q US EONL Y DAT EREC'D : AMOUN T REC'D : CHEC K NO. : PIC K UP : SENT :



### Pleas e submi t

you r complete d Orego nSoi l Matri x cleanu p Study Guid e for mto : Departmen t

ofEnvironmenta l Qualit y Attention : Busines s Offic e 81 1 S W6t hAvenu e Portland , Orego n9720 4 Ente r numbe r o f Stud y Guide s desire di nth e bo x below . 

# U Soi l Matri x Cleanu p Name : Addres s City , Stat e & Zi p Amount Remitte dfor Study Guide(s ) ( ^ $18.0 0 ea . Phone : *Shippin g an dHandlin g charge s @ $4.0 0 eac hStudy Guid e ordere d= $ _ Tota l remitte dfo r

Stud y Guide s plu s Shippin g an dHandlin g = $ _

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### *Notice : Shippin g an dhandlin g charge s d o no t appl y t o stud y guide s picke du p a t 81 1 S W6t h venu e o nth e 8t hfloor . o r assistanc e o

r questions , pleas e call (inOregon) 1-800-742-7878 , (outside Oregon) (503 ) 229-6652 , o r FA X (503 ) 229-6977 . Ma y 200 7 Pag e 1 o f 1 DEQ-06-LQ-020 A

# I

# -^5 ^ ' ^ M DE Q stat s of Orego n Departmen t o f Environmenta l Qualit y OREGO N DEPARTMEN TO F ENVIRONMENTA L QUALIT Y Undergroun d Storag e Tan k Progra m Soi l Matri xCleanu p 

## SERVIC E PROVIDE R LICENS E APPLICATIO N
Fo rtini s licens e applicatio n t o b e vali d th e tota l fee , th e lis t o fUS Tcleanu p project s complete d an d lis t o f license d supervisor s workin g fo rth e Servic e Provide rmus t accompan yit . Renewa l application s mus t b e submitte d 3 0 day s prio rt o expiration . Yo u shoul d receiv e you rlicens e fro m DE Q withi n on e t o tw o week s fro m th e dat e yo u submi t th e complet e application . Note : Ther e i s a separat e licens e require d t o perfor m heatin g oi l tan k

services . Pleas e retur n thi s application , fe e an d attachment s to : Departmen t o fEnvironmenta l Qualit y Attention : Busines s Offic e 81 1 SW . Sixt h Avenu e Portland , O R 9720 4 (3)Questions ? I n Oregon , cal l 1-800-742-787 8 Outsid e Oregon , cal l 503-229-665 2 / FAX : 503-229-697 7 FO RDE Q USEONL

Y LI C SM C Dat e Rec'd. : Amoun t Rec'd. : $ Chec k No. : Effectiv e Marc h 10 , 200 8 th e non-refundabl e licens e fe e i s $60 0 fo r2 4 month s Chec k (• ) th e appropriat e bo xbelow : Thi s applicatio n i s fo r QNe wLicens e L i Renewa l Licens e No.:

_• • ' • Expiratio n Date : ' 1 . SOI L MATRI X CLEANU P SERVIC E PROVIDE R INFORMATIO N FIR M PROVIDIN G US TCLEANU P SERVICE S Lega l Name^ : Address : Citv , State : Zi p Code : Telephon e No. : Contac t Person : E-Mai l Address . ^

: CORPORAT E HEADQUARTER S (I fDifferent ) Name : Address : Citv , State : Zi D Code : Telephon e No .


## ^pc i 2 . OREGO N CONSTRUCTIO N CONTRACTO R LICENS E C B Licens e Number : '^''f^0:^'V':'-'f^^^ ^ (i frequire d fo rth e typ e o f wor k you rfir m performs ) Chec k her e i f yo u ar e i n th e proces s o fobtainin g a Contractor s Licens e fro m th e Orego n Constructio n Contractor s Boar d (CCB) . Cal l 503-229-665 2 t o provid e th e licens e numbe rwhe n complete .

' A s registere d wit h th e Orego n Corporatio n Divisio n Marc h200 8 Pag e 1 o f 2 05-LQ-079 CUS

TSoi l Matri xCleanu p Service Provide rLicens e Applicatio n 3 . SUPERVISOR S Provid e th e nam e an d licens e numbe rfo reac h Soi l Matri xCleanu p Superviso ryou rfir m employs . Asuperviso rmus t be o n sit e a

t specifi ctime s o rsto p work . Attac h additiona l pages as needed . Superviso rName : Soi l Matri xCleanu p Licens e Number :

4 . SERVIC E ARE AAreas ofOrego n wher e you rfir m wil l provid e service s to th e public . Chec k as manythat appl y o rsimpl ychec k

Statewide . Se e ma p fo rdefinition s o fDE Q regions . Yo u must chec k a t leas t one . Statewid e | | Easter n j | Northwes t Wester n NORTHWESTREGION : Clackamas , Clatsop , Columbia , Multnomah , Tillamoo k & Washingto n Countie s

WESTER N REGION : Benton , Coos , Curry , Douglas , Jackson , Josephine , Polk , Lane , Lincoln , Unn , Mario n & Yamhil l Countie s EASTER N REGION : Baker , Crook , Deschutes , Gilliam , Grant , Hamey , Hood River , Jefferson , Klamath , Lake , Malheur , Mon'ow , Shemnan , Umatilla , Union , Wasco , Wheele r& Wallowa Countie s

5 . EXPERIENC E Attac h a summar yofUS Tcleanu p projects complete d i n Orego n durin g th e last 1 2 months , i f thi s i s a ne

wapplication , o n a separat e page , describ e you rcompany' s experience i n conductin g US Tcleanups . Chec k her e i fyou rcompan yha

s networke d o n anycleanu p projects durin g th e last 1 2 months . 

# • SAMPL EINFORMATIO N Compan yo rIndividua l Name/Addres s Sampl e Compan y 151 5 S E Champio n Wa y Portland , O R 9733 3 Typ e o f Projec t Soi l Matri xCleanu p Dat e Complete d

October , 200 0 Orego n LUS TFil e No . 26-00-999 9 6 . CERTIFICATIO N "/ , (you rname ) ••• ' • . ; : ; • , a m th e Chie fExecutiv e Office r(o rlega l equivalent ) o f(compan yname ) • ^ , an d d o hereb ycertif ytha t I hav e obtaine d a cop yo f th e applicabl e law s an d rule s pertainin g t o th e regulatio n o fUndergroun d Storag e Tank s I n th e Stat e o fOregon , an d tha t I hav e rea d the m an d wil l direc t th e employee s an d principal s o fthi s compan yt o perfor m th e tan k service s rendere d b ythi s compan yI n th e manne r tha t i s consisten t wit h thei rrequirements. " "B ym ysignatur e below , I stat e tha t th e Informatio n containe d I n thi s applicatio n i s tru e an d complet e t o th e bes t o fm yknowledge. " Signature : Name : Wi i Date : Title : (Mus

t b e ptincipa l i n th e firm ) Pag e 2 of2

# ^o ^

• ^ 

# DE Q Slat e ofOrego n Departmen t o f Environmenta l Qualit y 

### OREGO N DEPARTMEN TO F ENVIRONMENTA L QUALIT Y Undergroun d Storag e Tan k Progra m Soi l Matri xCleanu p 

## SUPERVISO R LICENS E APPLICATIO N

Pleas e retur n thi s applicatio n alon g wit h require d fe e an d exa m repor t to : 

### Departnnen t o f Envlronnnenta l Qualit y ATTENTION : Busines s Offic e 81 1 SWSixt h Avenu e Portland , O R 9720 4 (2)Questions ? I n Orego n cal l 1-800-742-787 8 Outsid e Orego n cal l (503 ) 229-665 2 FA X (503 ) 229-697 7 

### Complet e th e followin g information : FO RDE Q US EONL Y LI C SM C Dat e Rec'd : Amount Rec'd : Chec k No. :

APPLICAN T INFORMATIO N YOURNAME : ADDRESS : CITY : • STATE& ZIP : TELEPHONENo . • E-MAILADDRESS :

• EMPLOYE RINFORMATIO N COMPA>JYNAME : ADDRESS : CITY : STATE&ZIP : TELEPHONENo . E-MAI LADDRESS : 

### Effectiv e Jul y6 , 200 1 th e non-refundabl e licens e fe e i s $15 0 fo r2 4 month s Chec k (• ) th e appropriat e bo xbelow : Thi s applicatio n i s fo r

Renewa l Licens e No. : NewLicens e Expiratio n Date : ATTAC H th e passin g examinatio n documentatio n fo rOrego n Soi l Matri xCleanu p Superviso r Importan t Note : Ther e i s a separat e applicatio n for m an d licens e fe e fo rHeatin g Oi l Tan k Service s an d US TService s Superviso rlicenses . 

### Applican t Signature: . Date : Fo rthi s licens e applicatio n t o b e vali d i t mus t b e accompanie d b yth e tota l fe e an d th e passin g score repor t 

# J o u receive d fro m th e tes t administrator , LaserGrad e o rPearso n VU E (formerl yPromissor) . Licens e pplication s mus t b e submitte d t o DE O withi n 3 0 day s o f passin g th e qualifyin g examination . Renewa l application s mus t b e submitte d 3 0 day s prio rt o expiration . Yo u shoul d receiv e you rlicens e fro m DE Q withi n on e t o tw o week s fro m th e dat e yo u submi t th e complet e application .

Please notif yDE Q immediatel yo f an yaddres s changes s o yo u d o no t miss impoi-tan t bulletins ! Januar y 200 8 Page l o f 1 DEQ-05-LQ-080 B