^Stat e o f Orego n

Departmen t o f Envtronmanta l Qualit y 

### OREGO N DEPARTMEN T O F ENVIRONMENTA L QUALIT Y Undergroun d Storag e Tan k Progra m 

## US T SYSTE M MODIFICATIO N - 30-DA Y NOTIC E 1 . FACT T IT Y (Locatio n o f

Tanks ) 2 . PERMITTE E Name : ••„•' . Name : .,;,•:,•: • Address : Address :

Phone : Phone : DEO Facility I D Number : Work T o B e Performe dBy : License * (Permittee , Tan k

Owner , PrbiJert

y Owne r o r License dServic e Provider ) Phone : Mobil e Phone : (Servic e Provider ) 

## 1 THI S FOR M MUS T B E SUBMITTE D B Y TH E US T PERMITTE E3 0 DAY S BEFOR ESTAR T O FWOR K

YO U MUS T CONTAC T YOU RLOCA LDE Q REGIONA LOFFIC E 3 DAY S BEFOR E STARTIN GAN Y MODIFICATIO N WORK . Dat e work

i s schedule dt o begin : (Phon e number s for 3-da y telephon e notic e ar e listed.o n Pag e 2 ) TAN K U DEQ-US T

PERMI T # TAN K SIZ E I N GALLON S PRODUC T DESCRIB EWOR K T O B EPERFORMED : (Attac hseparat e sheet s if additiona l spac e i s needed ; includ e Tan k

#ah dPermi t

#. )

Permittee : 

# 1 Signature : (Pleas e Print ) Date : (Permittee ) Novembe r

200 7 Pag e lo f 2 DEQ-05-LQ-022 BTHI S NOTIC E AN D TH E 3-DA Y TELEPHON E NOTIC EAR EREQUIRE D prio r t o startm g work

t o modif y undergroun d storag e tank

components , includin g th e repai r o r replacemen t

o f meta l undergroim dpiping . Modificatio n include s bu t i s no t limite dt o undergroun dpipin g (product , ven t an dvapo r

recover y piping) , tank

lining , lea

k detectio n equipment , monitorin g an dobservatio n wells , an dcathodi c protection . (Se e OA R340-150-0352) . THI S NOTIC E I S NO T REQUIRE D for maintenanc e work

o n component s (replacemen t or repak ) o r

installation o f

aboveground ^ piping , suc ha s installation an dconnectio n o f dispenser s an dpump s t o undergroun dpiping . (Se e OA R340-150-035 0 & -0354) . THI S NOTIC E I S NO T REQUIRE D for installation o f

ane w tank

system . Instead , aGenera l Permi t Registratio n For mt o Instal l an dOperat e UST s an dth e appropriat e genera l permi t registratio n fe e mus t

b e submitte d30-day s prio r t o star t o f work . MAK E SUR E THI S FOR M I S COMPLETE . A notic e tha t i s incomplet e o r

unsigne dwill no t

b e accepte db y th e Departmen t an d wil l b e retume dt o permitte e fo r completion . RETUR N COMPLETE D AN D SIGNE D FOR M T O TH EDE Q REGIONA LOFFIC EFO RYOU RAREA . (Addresse s ar e liste dbelow) . N 3-DA Y NOTICE : Contac t you r loca l DE Q Regiona l Offic e 3-day s befor e startin g work . (Phon e number s ar e liste dbelow) . NORTHWES TREGION : Clackamas , Clatsop , Columbia , Multnomah , Tillamoo k & Wastiingto n Countie s

WESTER N REGION : Benton , Coos , Curry , Douglas , Jackson , Josephine , Polk , Lane , Lincoln , Linn , Mario n & Yamhil l Countie s EASTER N REGION : Baker , Crook , Deschutes , Gilliam , Grant , Harney , Hoo d River , Jefferson , Klamath , Lake , Malheur , Morrow , Sherman , Umatilla , Union , Wasco , Wheele r & Wallow a Countie s

EASTERN REGIO N /

TH E DALLE S 40 0 E . Sceni c Drive , Buildin g 2 - 30 7 Th e Dalles,.O R9705 8 Phone : 541-298-725 5 Fax : 541-298-733 0 WESTERN REGIO N /

EUGEN E 110 2 Lincoh i Street , Suit e 21 0 Eugene, O R9740 1 Phone : 541-686-783 8 Fax:541-686-755 1 NORTHWES T REGIO N 202 0 S W4thAvenue , Suit e 400 Portland , O R97201-588 4 Phone : 503-229-526 3 Fax : 503-229-694 5 WESTER N REGIO N /

SALE M 75 0 Fron t Stree t NE , Suit e 120 Salem , O R97301-103 9 Phone : 503-378-824 0 Fax : 503-373-794 4 WESTERN REGIO N / COO S BA Y 38 1 N Secon dStree t Coo s Bay 9742 0 Phone : 541-269-272 1 Fax : 541-269-798 4



### Fo r informatio n o r

assistanc e withthi s for

mcal l (503 ) 229-665 2 o r

th e US T HELPLINE : 1-800-742-787 8 (Tol l Fre e i n Oregon) . Progra minformation , registratio n forms , administrativ e rule s an d othe r publication s can als o b e foun don ou r We b Sit e at : http://www.deq.state.or.us/lq/tanks/ust/index.ht m

Novembe r

200 7 Pag e 2 of 2 DEQ-05-LQ-022 B^ < ^

^ 

## DE Q stat e o f Orego n Departmen t o f Environmenta l Qualit y 

### OREGO N DEPARTMEN T O FENVIRONMENTA LQUALIT Y Undergroun dStorag e Tan k Progra m 

# UNDERGROUN D STORAG E TAN K SYSTE M MODIFICATIO N REPOR T AN D CHECKLIS T



# w INSTRUCTIO N PAG E Thi s report

an dchecklis t

mus t b e fille dou t

b y th e DE Q license dsuperviso r an dsubmitte da s part

o f th e modificatio n recor di n accordanc e withOARChapte r 340 , Division s 15 0 an d160 . Thi s report an dchecklis t mus t als o b e use dt o repor t

o n th e repai r

o r replacemen t

o f meta l undergroun dpipin g an dfitting s (se e OAR 340-150-035 0 & -0354) . Th e DE Q license dUS T Servic e Provide r mus t hav e aDE Q license dSuperviso r o n sit e durin g al l modificatio n work . Thi s repor t an dchecklis t

mus t b e signe db y a n executiv e office r o f th e US T Servic e Provide r

firm , th e license dUS T Supervisor , an dth e permittee . Th e purpos e o f

thi s repor t

an dchecklis t

i s t o documen t

tha t th e modificatio n o f

undergroun dstorag e tan k (UST ) syste mcomponent s complie dwithOAR340-150-0352 . I t wil l als o b e use dt o recor dan y change s t o informatio n previousl y provide do n th e 30-day modificatio n notificatio n form . Th e permitte e mus t sig n th e odificatio n certificatio n statemen t o n pag e 7 . I f identica l modification s ar e performe do n all component s o f US T systems , pleas e complet e page s 3 , 4 , 5 , 6 an d7 jus t once . I f differen t wor k i s performe do n differen t US T systems , pleas e complet e aseparat e pag e 4 fo r eac hmodifie dUS T Syste malon g wit hpage s 3 , 5 , 6 an d7 jus t once . 

## IMPORTAN T REMINDER S

• Attac hdocumentation , includin g equipmen t receipts , fo r

an y equipmen t

tha t wa s modified , ^ includin g th e repai r

o r replacemen t

o f meta l pipin g an dfittings.

• Repor t

an y petroleum-contaminate dsoi l o r groundwate r

encountere dt o th e appropriat e DE Q Regiona l Offic e - fo r

offic e location s an dphon e number s se e pag e 2 . A sit e assessmen t mus t b e performe dt o characteriz e th e leve l o f soi l o r groundwate r

contamination .

• Loca l plannin g o r

fire departmen t

approval s o r

permit s ma y b e neede dbefor e modifyin g tan k an dassociate dpipin g systems . Complianc e wit hal l local , stat e an dfedera l requirement s i s necessar y whe n plannin g an dconductin g modificatio n o r additio n work .

Novembe r

200 7 Pag e 1 o f 7 DEQ-05-LQ-023 C

### • A cop y o f th e complete dfor mmus t b e maile dwithi n 3 0 day s o f completio n o f

th e tan k syste m modificatio n wor k

to :

• Th e appropriat e DE Q Regiona l Offic e (se e belo w fo r locations ) an dt o th e

• Departmen t

o f Environmenta l Qualit y US T Progra m 81 1 S W6 * Avenu e Portland , O R9720 4 

## DE Q Regiona l Office s - Addresse s an dPhon e Number s

NORTHWES TREGIO N Clackamas , Clatsop, Columbia , Multnomah , Tillamoo k & Washingto n Countie s

WESTER N REGION : Benton , Coos , Curry , Douglas , Jackson , Josephine , Polk , L3ne , Lincoln , Linn , Mario n & Yamhil l Countie s EASTER N REGION : Baker , Crook , Deschutes , Gilliam , Grant , Harney , Hoo d River , Jefferson , Klamath , Lake , Malheur , Morrow , / Sherman , Umatilla , Union , Wasco , Wheele r & Wallow a Countie s

EASTERN REGIO N /

TH E DALLE S 400 E . Sceni c Drive , Buildin g 2 - 30 7 Th e Dalles , O R9705 8 Phone : 541-298-725 5 Fax : 541-298-733 0 WESTER N REGIO N /

EUGEN E 110 2 Lincol n Street , Suite 21 0 Eugene , O R9740 1 Phone : 541-686-783 8 Fax:541-686-755 1 NORTHWES T REGIO N 202 0 S W4thAvenue , Suit e 400 Portland , O R97201-588 4 Phone : 503-229-526 3 Fax : 503-229-694 5 WESTER N REGIO N /

SALE M 750 Fron t Stree t NE , Suit e 12 0 Salem , O R97301-103 9 Phone : 503-378-824 0 Fax : 503-373-794 4 WESTER N REGIO N / COO S BA Y 3 8 I N Secon dStreet

Coo s Bay 9742 0 Phone : 541-269-272 1 Fax : 541-269-798 4

~~ ^


### Fo r informatio n o r

assistanc e wit hthi s for mcal l (503 ) 229-665 2 o r th e US T HELPLINE : 1-800-742-787 8 (Tol l Fre e i n Oregon) . Progra minformation , registratio n forms , administrativ e rule s an d othe r publication s ca n als o b e foun do n ou r We b Sit e at : http://www.deq.state.or.us/lq/tanks/ust/index.ht m

Novembe r

200 7 Pag e 2 o f 7 DEQ-05-LQ-023 C'-< ^

^ 

# DE Q stat e of Orego n Departmen t of

f Environmenta l Qualit y 

### OREGO N DEPARTMEN T O FENVIRONMENTA LQUALIT Y Undergroun dStorag e Tan k Progra m 

# UNDERGROUN D STORAG ETAN K SYSTE M MODIFICATIO N REPOR T AN D CHECKLIS T
Modificatio n wor k

conducte da t

on e US T facilit y ma y b e reporte dtogethe r b y completin g page s 3 , 4 , 5 , 6 , an d7 onc e fo r

th e entir e facility . Mak e additiona l copie s o f pag e 4 , a s needed . 1 . US T SYSTE M PERMITTE EAN D LOCATIO N (PLEAS E PRINT) : DE Q Facility I D Ntimber : DE Q US T Facilit y Name : Facility (location ) Address :

US T permitte e name : Permitte e mailin g address : Permitte e Telephone :

2 . TAN K

MODIFICATIO N O RADDITIO N PERFORME D BY : Servic e Provider : DE Q Licens e Numbe r Address : (Pleas e Print ) Lie . Expiratio n Date : Telephone: ^ ;

•
License dSupervisor : DE Q Licens e Numbe r wmm::mmmmmmm:i (Pleas e Print ) Lie . Expiratio n Date : ss::liiliili;|iiiii:iiii :

Novembe r

200 7 Pag e 3 o f 7 DEQ-05-LQ-023 C

# IMPORTAN T NOT E REGARDIN GUS E O FTHI S PAG E (Pag e 4 o f 7 ) I f th e sam e wor k

i s complete do n eac htan k an dassociate dpipin g system , fil l ou t thi s pag e jus t

once . If

j differen t wor k i s complete do n eac htan k an dassociate dpipin g system , mak e copie s o f thi s pag e an dfill' on e ou t fo r eac htan k

an dassociate dpipin g syste mtha t ha s bee n modified , adde dto , o r tha t ha s ha d meta l undergroun dpipin g an dfittings repaire do r replaced . 

### 3 . TAN K

AN D ASSOCIATE D PIPIN GSYSTE M INFORMATIO N TAN K #

••'•l'..•;- . DEQ-US T

PERMI T # TAN K SIZ E I N GALLON S

~ i PRODUC T STORE D CURREN T FUTUR E TYP EO FASSOCLVTE D PIPIN G (i . e . metal, fiberglass , flexible , single-walled , double-walled , etc. ) CURREN T FUTUR E



### 4 . MODIFICATIO N AN D META LPIPING , REPAI RO RREPLACEMENT ^ INFORMATIO N (Pleas e writ e anarrativ e descriptio n ofth e wor k that was completed) .

Novembe r

200 7 Pag e 4 o f 7 DEQr-05-LQ-023 C

# « l 5 . CHECKLIST : (Chec k YE S o r NO . Wher e aspecifi c ite mi s "no t apphcable " t o th e situation , pleas e chec k

th e N/ A box )

Wa s th e DE Q Regiona l Offic e notifie dat leas t 3 0 day s i n advanc e o f th e planne d modificatio n o r

addition start

date ? Wa s th e DE Q Regiona l Offic e notifie d7 2 hour s i n advanc e prio r t o beginnin g th e modificatio n o r

addition ? I f

yes , indicat e 3-day numbe r issued : •": " '.•••::' '•••••-

' ""'".' • • Wa s extema l cathodi c protectio n (CP ) installed , modifie do r adde dto ? Wa s aseparat e C P report submitte do r

attached ? Wa s aC P tes t

statio n installed ? I s a6-mont

hC P follow-u p inspection/tes t scheduled ? Projecte dinspectio n date : • " Wa s asit e assessmen t

conducted ? Wa s contamination , includin g simpl e overfill , encountere dan dwa s it reporte dt o DEQ ? I f so ; indicat e DE Q LUS T numbe r issued : __I

_"
____"
___: ^ _! . Ii : Wer e intema l inspection s o f al l UST s complete dbefor e linin g bega n o n an y UST ? Hav e th e result s o f

th e intema l tan k

inspection s bee n submitte dt o and/o r discusse dwith DEQ ? I f ther e wer e hole s i n an y o f th e USTs , ha s aSUSPECTE D releas e bee n reporte dt o DEQ ? I f yes , indicat e dat e reported : . . : ' ' • ' ' • • • '"'"•• . • '•^••-:.- ' Wa s th e syste mtight-teste dbefore placin g bac k int o service ? D o al l tan k

an dpipin g material s compl y withOA R340-150-0300 ? Hav e al l item s checke dabov e bee n modifie do r adde dt o in accordanc e withal l codes , manufacturer' s requirement s an dfederal an dstat e regulations ? Ha s th e US T syste mpermitte e bee n provide dwit hwritte n documentatio n o f th e item(s ) modifie do r

adde dt o an dha s th e permitte e bee n instructe dt o preserv e thes e records ? YE S N O 

# 1 1 I I 1 t 1 

# u 1 1 

# n 1 1 1 

# n I I F l \ 4 

# m N/

A 

# l_J 

# 1 1

r1 

# \ 1

November

2007 Pag e 5 o f 7 DEQ-05-LQ-023 C

### 6 . AS-BUIL T DRAWIN G O FTAN K SYSTE M MODIFICATIO N

Attac hdocumentation , includin g equipmen t receipts , fo r

an y equipmen t

tha t wa s modified , includin g th e repai r

o r replacemen t

o f meta l pipin g an dfittings. Novembe r

200 7 Pag e 6 o f 7 DEQ-05-LQ-023 C7 . SUPERVISOR' S OATH : I certif y tha t I hav e bee n th e Orego n DE Q license dsuperviso r presen t o n site durin g th e abov e liste dmodificatio n wor k an dt o th e bes t

o f my knowledg e th e work

ha s bee n conducte di n complianc e withal l local , stat e an dfederal laws , regulation s an dindustry standard s an dprocedure s pertainin g t o undergroun dstorag e tan k systems . I further

certif y tha t th e informatio n containe di n thi s report an dchecklis t i s tru e t o th e bes t

o f my belie f

an dknowledge . Supervisor : (Prin t Name ) (Signature ) Servic e Provider : Date : US T Servic e Provide r

Firm , Executiv e Officer : (Prin t Name ) (Signature ) (Date) 8 . US T PERMITTE E MODIFICATIO N CERTIFICATIO N STATEMENT : I hereb y certif

y tha t th e informatio n provide do n thi s report an dchecklis t

concemin g the . modificatio n work o n my tan k an dassociate dpipin g syste mi s accurate . (Prin t Permitte e Name ) (Signature ) (Date)

Fo r information , cal l th e appropriat e DE Q Regiona l Offic e (se e Pag e 2 ) o r th e tol l fre e number , 1

- 800-742-7878 . Tw o copie s o f thi s for mmus t

b e maile dwithi n 3 0 day s afte r th e modificatio n o r additio n wor k

i s complete dto : 1 . On e cop y t o th e appropriat e DE Q Regiona l Offic e (se e pag e 2 ) Chec k her e tha t

thi s cop y ha s bee n maile d 2 . On e cop y t o th e US T Progra mOffic e at : Departmen t

o f Environmenta l Qualit y US T Progra m 81 1 S W6 * Avenu e Portland , O R9720 4 Chec k her e tha t

thi s cop y ha s bee n maile d DE Q INSPECTIONS : Thi s for mma y b e usedb

y DEQ Inspector s fo

r oversigh t purposes . A DE

Q inspecto r i s not requiredto inspect

the modification . ,

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

November

2007 Pag e 7 o f 7 DEQ-05-LQ-023 C