^ 
State of Oregon 

Department of 

Envtronmantal 

Quality 

OREGON DEPARTMENT OF ENVIRONMENTAL QUALITY 

Underground Storage Tank Program 

UST SYSTEM MODIFICATION - 30-DAY NOTICE 

1. FACTT ITY (Location of Tanks) 2. PERMITTEE 

Name: ••„•' . Name: .,;,•:,•:• 

Address: Address: 

Phone: Phone: 

DEO Facility ID Number: 

Work To Be Performed By: License* 

(Permittee, Tank Owner, PrbiJerty Owner or Licensed Service Provider) 

Phone: Mobile Phone: 

(Service Provider) 

1 

THIS FORM MUST BE SUBMITTED BY THE UST PERMITTEE 30 DAYS BEFORE START OF WORK 

YOU MUST CONTACT YOUR LOCAL DEQ REGIONAL OFFICE 

3 DAYS BEFORE STARTING ANY MODIFICATION WORK. 

Date work is scheduled to begin: (Phone numbers for 3-day telephone notice are listed.on Page 2) 

TANK 

U 

DEQ-UST 

PERMIT # 

TANK SIZE 

IN 

GALLONS 

PRODUCT DESCRIBE WORK TO BE PERFORMED: 

(Attach separate sheets if additional space is needed; 

include Tank # ahd Permit #.) 

Permittee: 

1 Signature: 

(Please Print) 

Date: 

(Permittee) 

November 2007 Page lo f 2 DEQ-05-LQ-022B 
THIS NOTICE AND THE 3-DAY TELEPHONE NOTICE ARE REQUIRED prior to startmg work to modify underground 

storage tank components, including the repair or replacement of metal undergroimd piping. Modification includes but is not limited to 

underground piping (product, vent and vapor recovery piping), tank lining, leak detection equipment, monitoring and observation 

wells, and cathodic protection. (See OAR 340-150-0352). 

THIS NOTICE IS NOT REQUIRED for maintenance work on components (replacement or repak) or installation of aboveground^ 

piping, such as installation and connection of dispensers and pumps to underground piping. (See OAR 340-150-0350 & -0354). 

THIS NOTICE IS NOT REQUIRED for installation of a new tank system. Instead, a General Permit Registration Form to Install 

and Operate USTs and the appropriate general permit registration fee must be submitted 30-days prior to start of work. 

MAKE SURE THIS FORM IS COMPLETE. A notice that is incomplete or unsigned will not be accepted by the Department and 

will be retumed to permittee for completion. 

RETURN COMPLETED AND SIGNED FORM TO THE DEQ REGIONAL OFFICE FOR YOUR AREA. 

(Addresses are listed below). N 

3-DAY NOTICE: Contact your local DEQ Regional Office 3-days before starting work. 

(Phone numbers are listed below). 

NORTHWEST REGION: 

Clackamas, Clatsop, 

Columbia, Multnomah, 

Tillamook & Wastiington 

Counties 

WESTERN REGION: Benton, 

Coos, Curry, Douglas, Jackson, 

Josephine, Polk, Lane, Lincoln, 

Linn, Marion & Yamhill Counties 

EASTERN 

REGION: 

Baker, Crook, 

Deschutes, 

Gilliam, Grant, 

Harney, Hood 

River, Jefferson, 

Klamath, Lake, 

Malheur, 

Morrow, 

Sherman, 

Umatilla, Union, 

Wasco, Wheeler 

& Wallowa 

Counties 

EASTERN REGION / THE DALLES 

400 E. Scenic Drive, Building 2 - 307 

The Dalles,.OR 97058 

Phone: 541-298-7255 

Fax: 541-298-7330 

WESTERN REGION / EUGENE 

1102 Lincohi Street, Suite 210 

Eugene, OR 97401 

Phone: 541-686-7838 

Fax:541-686-7551 

NORTHWEST REGION 

2020 SW 4th Avenue, Suite 400 

Portland, OR 97201-5884 

Phone: 503-229-5263 

Fax: 503-229-6945 

WESTERN REGION / SALEM 

750 Front Street NE, Suite 120 

Salem, OR 97301-1039 

Phone: 503-378-8240 

Fax: 503-373-7944 

WESTERN REGION / COOS BAY 

381 N Second Street 

Coos Bay 97420 

Phone: 541-269-2721 

Fax: 541-269-7984 

For information or assistance with this form call (503) 229-6652 or the UST HELPLINE: 

1-800-742-7878 (Toll Free in Oregon). 

Program information, registration forms, administrative rules and 

other publications can also be found on our Web Site at: 

http://www.deq.state.or.us/lq/tanks/ust/index.htm 

November 2007 Page 2 of2 DEQ-05-LQ-022B 

^ < ^ 

^ 

DEQ 

state of Oregon 

Department of 

Environmental 

Quality 

OREGON DEPARTMENT OF ENVIRONMENTAL QUALITY 

Underground Storage Tank Program 

UNDERGROUND STORAGE TANK SYSTEM 

MODIFICATION REPORT AND CHECKLIST 

w 

INSTRUCTION PAGE 

This report and checklist must be filled out by the DEQ licensed supervisor and submitted as part of the 

modification record in accordance with OAR Chapter 340, Divisions 150 and 160. This report and checklist 

must also be used to report on the repair or replacement of metal underground piping and fittings (see OAR 

340-150-0350 & -0354). The DEQ licensed UST Service Provider must have a DEQ licensed Supervisor on 

site during all modification work. This report and checklist must be signed by an executive officer of the UST 

Service Provider firm, the licensed UST Supervisor, and the permittee. 

The purpose of this report and checklist is to document that the modification of underground storage tank 

(UST) system components complied with OAR 340-150-0352. It will also be used to record any changes to 

information previously provided on the 30-day modification notification form. The permittee must sign the 

odification certification statement on page 7. 

If identical modifications are performed on all components of UST systems, please complete pages 3, 4, 5, 6 

and 7 just once. If different work is performed on different UST systems, please complete a separate page 4 for 

each modified UST System along with pages 3, 5, 6 and 7 just once. 

IMPORTANT REMINDERS 

• Attach documentation, including equipment receipts, for any equipment that was modified, ^ 

including the repair or replacement of metal piping and fittings. 

• Report any petroleum-contaminated soil or groundwater encountered to the appropriate DEQ 

Regional Office - for office locations and phone numbers see page 2. A site assessment must be 

performed to characterize the level of soil or groundwater contamination. 

• Local planning or fire department approvals or permits may be needed before modifying tank 

and associated piping systems. Compliance with all local, state and federal requirements is 

necessary when planning and conducting modification or addition work. 

November 2007 Page 1 of 7 DEQ-05-LQ-023C 
• A copy of the completed form must be mailed within 30 days of completion of the tank system 

modification work to: 

• The appropriate DEQ Regional Office (see below for locations) and to the 

• Department of Environmental Quality 

UST Program 

811 SW 6* Avenue 

Portland, OR 97204 

DEQ Regional Offices - Addresses and Phone Numbers 

NORTHWEST REGION 

Clackamas, Clatsop, 

Columbia, Multnomah, 

Tillamook & Washington 

Counties 

WESTERN REGION: Benton, 

Coos, Curry, Douglas, Jackson, 

Josephine, Polk, L3ne, Lincoln, 

Linn, Marion & Yamhill Counties 

EASTERN 

REGION: 

Baker, Crook, 

Deschutes, 

Gilliam, Grant, 

Harney, Hood 

River, Jefferson, 

Klamath, Lake, 

Malheur, 

Morrow, / 

Sherman, 

Umatilla, Union, 

Wasco, Wheeler 

& Wallowa 

Counties 

EASTERN REGION / THE DALLES 

400 E. Scenic Drive, Building 2 - 307 

The Dalles, OR 97058 

Phone: 541-298-7255 

Fax: 541-298-7330 

WESTERN REGION / EUGENE 

1102 Lincoln Street, Suite 210 

Eugene, OR 97401 

Phone: 541-686-7838 

Fax:541-686-7551 

NORTHWEST REGION 

2020 SW 4th Avenue, Suite 400 

Portland, OR 97201-5884 

Phone: 503-229-5263 

Fax: 503-229-6945 

WESTERN REGION / SALEM 

750 Front Street NE, Suite 120 

Salem, OR 97301-1039 

Phone: 503-378-8240 

Fax: 503-373-7944 

WESTERN REGION / COOS BAY 

38 I N Second StreetCoos Bay 97420 

Phone: 541-269-2721 

Fax: 541-269-7984 

~~^ 

For information or assistance with this form call (503) 229-6652 or the UST HELPLINE: 

1-800-742-7878 (Toll Free in Oregon). 

Program information, registration forms, administrative rules and 

other publications can also be found on our Web Site at: 

http://www.deq.state.or.us/lq/tanks/ust/index.htm 

November 2007 Page 2 of 7 DEQ-05-LQ-023C 
'-< ^ 

^ 

DEQ 

state of Oregon 

Department off 

Environmental 

Quality 

OREGON DEPARTMENT OF ENVIRONMENTAL QUALITY 

Underground Storage Tank Program 

UNDERGROUND STORAGE TANK SYSTEM 

MODIFICATION REPORT AND CHECKLIST 

Modification work conducted at one UST facility may be reported together by completing pages 3, 4, 5, 6, 

and 7 once for the entire facility. Make additional copies of page 4, as needed. 

1. UST SYSTEM PERMITTEE AND LOCATION (PLEASE PRINT): 

DEQ Facility ID Ntimber: 

DEQ UST Facility Name: 

Facility (location) Address: 

UST permittee name: 

Permittee mailing address: 

Permittee Telephone: 

2. TANK MODIFICATION OR ADDITION PERFORMED BY: 

Service Provider: DEQ License Number 

Address: 

(Please Print) 

Lie. Expiration Date: 

Telephone:^ ;• 

Licensed Supervisor: DEQ License Number wmm::mmmmmmm:i 

(Please Print) Lie. Expiration Date: ss::liiliili;|iiiii:iiii: 

November 2007 Page 3 of 7 DEQ-05-LQ-023C 
IMPORTANT NOTE REGARDING USE OF THIS PAGE (Page 4 of 7) 

If the same work is completed on each tank and associated piping system, fill out this page just once. Ifj 

different work is completed on each tank and associated piping system, make copies of this page and fill' 

one out for each tank and associated piping system that has been modified, added to, or that has had 

metal underground piping and fittings repaired or replaced. 

3. TANK AND ASSOCIATED PIPING SYSTEM INFORMATION 

TANK # 

••'•l'..•;- . 

DEQ-UST 

PERMIT # 

TANK SIZE 

IN 

GALLONS 

~i 

PRODUCT 

STORED 

CURRENT FUTURE 

TYPE OF ASSOCLVTED PIPING 

(i. e. metal, fiberglass, flexible, single-walled, double-walled, etc.) 

CURRENT FUTURE 

4. MODIFICATION AND METAL PIPING, REPAIR OR REPLACEMENT^ 

INFORMATION (Please write a narrative description ofthe work that was completed). 

November 2007 Page 4 of 7 DEQr-05-LQ-023C 
«l 5. CHECKLIST: (Check YES or NO. Where a specific item is "not apphcable" to the situation, 

please check the N/A box) 

Was the DEQ Regional Office notified at least 30 days in advance of the planned 

modification or addition start date? 

Was the DEQ Regional Office notified 72 hours in advance prior to beginning the 

modification or addition? If yes, indicate 3-day number issued: •":" '.•••::' '•••••-' ""'".'• • 

Was extemal cathodic protection (CP) installed, modified or added to? 

Was a separate CP report submitted or attached? 

Was a CP test station installed? 

Is a 6-month CP follow-up inspection/test scheduled? 

Projected inspection date: • " 

Was a site assessment conducted? 

Was contamination, including simple overfill, encountered and was it reported to DEQ? 

If so; indicate DEQ LUST number issued: __ I_ " __ __ " __ _:^ _!. Ii: 

Were intemal inspections of all USTs completed before lining began on any UST? 

Have the results of the intemal tank inspections been submitted to and/or discussed with 

DEQ? 

If there were holes in any of the USTs, has a SUSPECTED release been reported to 

DEQ? If yes, indicate date reported: .. :' '• ' ' •• • '"'"••. • '•^••-:.-' 

Was the system tight-tested before placing back into service? 

Do all tank and piping materials comply with OAR 340-150-0300? 

Have all items checked above been modified or added to in accordance with all codes, 

manufacturer's requirements and federal and state regulations? 

Has the UST system permittee been provided with written documentation of the item(s) 

modified or added to and has the permittee been instructed to preserve these records? 

YES NO 

1 1 

I I 

1 

t 1 

u 

1 

1 

n 

1 1 

1 

n 

I I 

Fl 

\4 

m 

N/A 

l_J 

1 1 

r 1 

\ 1 

November 2007 Page 5 of 7 DEQ-05-LQ-023C 
6. AS-BUILT DRAWING OF TANK SYSTEM MODIFICATION 

Attach documentation, including equipment receipts, for any equipment that was modified, including 

the repair or replacement of metal piping and fittings. 

November 2007 Page 6 of 7 DEQ-05-LQ-023C 
7. SUPERVISOR'S OATH: I certify that I have been the Oregon DEQ licensed supervisor present on site 

during the above listed modification work and to the best of my knowledge the work has been conducted in 

compliance with all local, state and federal laws, regulations and industry standards and procedures pertaining 

to underground storage tank systems. I further certify that the information contained in this report and checklist 

is true to the best of my belief and knowledge. 

Supervisor: 

(Print Name) (Signature) 

Service Provider: Date: 

UST Service Provider Firm, Executive Officer: 

(Print Name) (Signature) (Date) 

8. UST PERMITTEE MODIFICATION CERTIFICATION STATEMENT: 

I hereby certify that the information provided on this report and checklist conceming the. modification work on 

my tank and associated piping system is accurate. 

(Print Permittee Name) (Signature) (Date) 

For information, call the appropriate DEQ Regional Office (see Page 2) or the toll free number, 1-

800-742-7878. Two copies of this form must be mailed within 30 days after the modification or 

addition work is completed to: 

1. One copy to the appropriate DEQ Regional Office (see page 2) 

Check here that this copy has been mailed 

2. One copy to the UST Program Office at: 

Department of Environmental Quality 

UST Program 

811 SW 6* Avenue 

Portland, OR 97204 

Check here that this copy has been mailed 

DEQ INSPECTIONS: This form may be used by DEQ Inspectors for oversight purposes. A DEQ inspector is not 

required to inspect the modification. , 

DEQ Inspector's Signature: Inspection Date(s): 

November 2007 Page 7 of 7 DEQ-05-LQ-023C