^ < ^ 

^ 

DEQ 

state of Oregon 

Department of 

Environmenlal 

Quality 

OREGON DEPARTMENT OF ENVIRONMENTAL QUALITY 

UNDERGROUND STORAGE TANK PROGRAM 

GENERAL PERMIT REGISTRATION FORM 

AND 30-DAY NOTICE 

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Complete one general permit registration package for each separate 

facility you are registering. 

Each registration package Includes the registration form (pages 7 & 8) with 

signature blocks, a fee matrix to calculate the required registration fee 

(page 7) and the notification and description of underground storage tank 

systems (pages 9, 10 & 11). 

If you are installing more than five (5) tanks, please make additional 

copies of the description pages (pages 9, 10 & 11) and list the additional 

tanks on the copies you make. 

You must call your regional office to receive authorization to proceed with 

the installation 72 hours prior to beginning work. See page 4 for office 

locations. 

CHECKLIST 

^ Be sure signatures are provided for the tank owner, permittee and property owner, 

even where one person fills all three roles. 

^ Complete the registration form (pages 7 and 8) and the notification and description of 

underground storage tank systems (pages 9, 10 & 11) for all tanks being installed at 

the facility. 

^ Make copies for your records. 

v^ Enclose your check payable to: 

Oregon Department of Environmental Quality 

^ Retum the general permit registration form (pages 7 and 8), the notification and 

description of underground storage tank systems (pages 9, 10'& 11) and the correct 

total fee amount to: 

DEQ 

Business Office 

811 SW 6**'Avenue 

Portland, Oregon 97204 

January 2008 Page lo f 11 DEQ-05-LQ-016A 
GENERAL INFORMATION PAGE 

DESCRIPTION OF GENERAL PERMIT PROGRAM 

In lieu of issuing individual pennits, Oregon's UST permitting program has adopted general 

permits by rule'as follows: 

General Permit to Install (OAR 340-150-0160): this rule identifies the conditions and 

requirements that cover the construction of an UST system. 

General Permit to Operate (OAR 340-150-0163): this rule identifies the conditions and 

requirements that covers the operation of an UST system that meets the performance 

standards.for new or upgraded facilities. Facilities registering for a general permit to 

operate are authorized to deposit a regulated substance such as motor fuel into an UST. 

By signing the registration forms, you are certifying that you will comply with all the conditions 

and requirements ofthe general permits to install and operate. Upon receipt ofthe completed 

registration forms, the Department will issue a Registration Certificate to Install. This certificate 

does not authorize fuel delivery. To receive a Certificate to Operate authorizing fuel delivery 

you must submit to your DEQ regional office the following documentation: 

1. UST Installation Checklist, 

2. Information associated with the equipment installed including a list of major system 

components, third-party evaluations, manufacturers' checklists, photographs and fire 

authority sign-off, if available. 

When you receive your Certificate to Operate you must provide the Operating Certificate Number 

to your fuel distributor so they can deliver product to your facility. 

DEFINITIONS 

Install - means the physical construction of all or part of an underground tank, including but not 

limited to, activities such as excavating; backfilling; testing; proper placement of tank, piping, 

release detection devices; corrosion protection systems, spill and overfill devices and any 

associated administrative activities such as notifications, record keeping and record submissions. 

Operate - means depositing a regulated substance into, storing a regulated substance in or 

dispensing a regulated substance from an underground storage tank and such other activities, 

including but not limited to, performing release detection, maintaining corrosion control, 

preventing spills and overfills, investigating and confirming suspected releases, conducting 

maintenance, modifications, replacement and repairs of equipriient, maintaining financial 

responsibility and submitting records on the UST and underground piping's performance. 

Owner - means a person who currently owns an UST or owned an UST during the operational 

life ofthe tank. If registered with the Secretary of State, Corporations Division, the tank owner is 

the legal business name. 

Permittee - means the owner or person designated by the owner, who is in control or has 

responsibility for daily UST system operation and maintenance, financial responsibility and UST 

operator training requirements under a general permit pursuant to OAR 340-150-0160 through 

340-150-0168. If registered with the Secretary of State, Corporations Division, the permittee is 

the legal business name. The permittee is mailed the annual compliance fee invoice. 

Property Owner - means the legal owner ofthe real property on which an UST is located (the 

name that appears on the County deed records). 

Registration Certificate - the document the Department issues to acknowledge receipt of a 

general permit registration form. The registration certificate to operate authorizes delivery of 

regulated substances, including motor fuels. The registration certificates to install, decommission 

or manage a system in temporary closure do not authorize product deliveries. 

SIC Code - Standard Industrial Code (see pages 5 & 6) 

January 2008 ^ Page 2 of 11 DEQ-05-LQ-016A 
INSTRUCTION PAGE 

TANKS REQUIRING A GENERAL PERMIT REGISTRATION 

FORM 

1. All underground tanks, mcluding emergency generator tanks, containing petroleum products or listed 

chemicals, which are not exempt (examples are gasoline, diesel, industrial solvents, pesticides and 

herbicides). 

2. Tanks and piping with 10% or more of their total volume beneath the ground. 

3. Farm or residential motor fuel underground tanks larger than 1,100 gallons in capacity. 

4. Tanks containing regulated substances and not permanently decommissioned prior to May 1, 1988. 

EXEMPT TANKS (GENERAL PERMIT REGISTRATION NOT 

REQUIRED) 

1. Farm or residential motor fuel tanks of 1,100 gallon capacity or less. 

2. Heating oil tanks used for heat on the same property where the tanks are located. 

3. Septic Tanks. 

4. Pipeline Facilities. 

5. Surface Impoundments. 

6. Storm Water or Waste Water Collection Systems 

7. Flow-Through Process Tanks. 

8. Liquid Traps. 

9. Tanks that are above the surface ofthe floor m an underground area. 

GENERAL PERMIT REGISTRATION FORM 

1. Please fill in the name, address and phone number ofthe facility. Include the Facility E) number if 

this form is being submitted for an existing facility that has previously registered other tanks. 

2. Please provide the SIC code for each facility (See pages 5 and 6). 

3. For new tanks, a registration fee of $ 135.00 per tank and an installation fee of $400 per tank are due 

for the current year. For multi-chambered or multi-compartment tank, the registration fee is $135.00 

and the installation fee $400 for each chamber or compartment. Please fill in the number of new tanks 

or compartments in the space provided in the general pennit registration fee section. Multiply this 

number by $535 to calculate the total amount owed. 

4. Please fill in the tank owner's legal name, address and phone number. The legal name is the name of 

the tank owner as filed with the Secretary of State, Corporations Division, if applicable. The tank 

owner must sign the registration form. 

5. The tank owner can name a permittee for each facility. Please ask the permittee in charge ofthe 

facility to fill in their legal name, address and phone number. The legal name is the name ofthe 

permittee as filed with the Secretary of State, Corporations Division, if applicable. The permittee must 

sign the registration form. 

6. Please fill in the property owner's name, address and phone number. The property owner's name 

should be the name tn the county deed records. The property owner must sign the registration form. 

7. There must be three signatures for each completed registration form - the tank owner, permittee and 

property owner. IF ONE PERSON FILLS ALL THREE ROLES, THAT PERSON MUST SIGN 

THREE TIMES. 

8. Complete pages 9, 10 and 11, Notification and Description of Underground Storage Tank Systems. 

LICENSED SERVICE PROVIDERS AND SUPERVISORS 

ORS 466.750 and OAR Chapter 340, Division 160 requires that licensed service providers perform tank 

installation work. NOTE: AN OWNER OR PERMITTEE MAY PERFORM UST SERVICES ONLY 

IF THEY HAVE TAKEN AND PASSED THE APPROPRL\TE UST SUPERVISOR 

EXAMINATION OFFERED BY A NATIONAL TESTING SERVICE (OAR 340-150-0156). During 

certain critical phases as specified in the rules, a licensed supervisor must be present on site to monitor the 

work. Lists of licensed service providers and supervisors are available upon request by calling (503) 229-

6652 or toll-fi-ee in Oregon 1-800-742-7878 (a message answering machine). 

January 2008 Page 3 of 11 DEQ-05-LQ-016A 
INSTRUCTION PAGE 

UST SYSTEM OPERATOR REQUIRED 

The owner or permittee of each UST facility issued an operating certificate that dispenses a regulated 

substance from an UST to a motor vehicle or container must employ trained personnel who can 

properly operate and maintain the UST system and provide emergency response mformation to any person 

that dispenses a regulated substance from the UST system. For more details on implementing this 

requirement see rule OAR 340-150-0200 or go to http://www.deq.state.or.us/lq/training.htm#training. 

HELP WITH THIS REGISTRATION FORM 

If you have any questions about this registration form, please phone the DEQ UST Program at (503) 229-

6652. You can also phone the UST Program's toll-fi-ee number, 1-800-742-7878. This is a message 

answering machine for calls made within Oregon. Underground Storage Tank Program staff will retum 

your calls within 24 hours. You can also send an e-mail to tanks.info@.deq.State.or.us. Our regional 

staff are also available to answer questions regarding the general permit program and this general permit 

registration form (see below for telephone numbers). 

COPIES OF GENERAL PERMIT CONDITIONS AND 

REQUIREMENTS AND UST PROGRAM RULES 

/ 

Copies ofthe general permit to mstall and operate conditions and requirements and UST Program rules and 

laws can be obtained from: 

1. Any of the DEQ offices Hsted below, 

2. By calling the UST HELPLINE at 1-800-742-7878, 

3. Send an e-mail to tanks.info(3>cleq.state.orus or 

4. Downloading fi-om the UST home page at: 

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

NORTHWEST REGION: 

Clackamas, Clatsop, 

Columbia, Multnomah, 

Tillamook & Washington 

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 

Phone: 541-298-7255 

NORTHWEST REGION / PORTLAND 

Phone: 503-229-5263 

WESTERN REGION / COOS BAY 

Phone: 541-269-2721 

WESTERN REGION / EUGENE 

Phone: 541-686-7838 

UST HELPLINE (IN OREGON): 

WESTERN REGION / SALEM 

Phone: 503-378-8240 

1-800-742-7878 

January 2008 Page 4 of 11 DEQ-05-LQ-016A 
INDEX OF SELECT STANDARD INDUSTRIAL CODES 

STANDARD INDUSTRIAL CODES FOR UNDERGROUND STORAGE 

hTANKS 

The Standard Industrial Classification (SIC) Code was developed by ttie Federal 

Govemment to aid in gathering economic statistics and to help compare infonnation from 

different govemment agencies. The Department of Environmental Quality (DEQ) uses SIC 

codes to analyze underground storage tank locations and to identify the businesses that 

own tanks. 

SIC codes define industries according to their economic structure. They classify businesses 

by their main activities and other measures of economic activity. (These SIC codes are NOT 

the same as those used on tax forms. Please refer to this list for the con-ect SIC code). 

DEQ has determined that this list of SIC codes will describe many of the businesses that 

have underground storage tanks in Oregon. If your business is not listed, the complete list of 

SIC codes can be found in the reference section of your local library in the "Standard 

Industrial Classification Manual" for 1987. Please use the 1987 manual since it lists the 

correct, revised SIC codes. 

Please use the FOUR digit code that describes the main activity of your business. Find the 

con-ect division, being careful when selecting manufacturing, wholesale or retail. (There are 

similar codes in each of these categories.) Then find the major group that describes your 

business. The fOW? digit code should be listed within that major group. For assistance, 

please contact the UST Compliance Section, (503) 229-6652. 

DIVISION A - AGRICULTURE, FORESTRY & FISHING 

CROPS 

0111 Wheat-Cash Grains 

0139 Field Crops -Alfalfa, Clover, Grass Seed, Hops 

0161 Vegetables And Melons 

0172 Grapes 

0173 Tree Nuts - Filberts, Walnuts 

0175 Deciduous Tree Fruits -Apples, Apricots, Chemes, Peach, Pear, Plum, Prune 

0181 Ornamental Floriculture & Nursery Products 

0182 Food Crops Grown Under Cover - Bean Sprouts, Greenhouses, Mushrooms 

0191 General Farms - Crops 

LIVESTOCK 

0211 Beef Cattle-Feedlots 

8212 . Beef Cattle, Except Feedlots 

P213 Hogs 

'0214 Sheep & Goats 

0219 General Livestock, Except Dairy & Poultry 

0241 Dairy Fanns 

0251 Broiler, Fryer & Roaster Chickens 

0252 Chicken Eggs 

0253 Turi<eys & Turi<ey Eggs 

0254 Poultry Hatcheries 

0279 Animal Specialties - Other (Bee Farms, Cat Farms, Dog Farms, Honey Production) 

0291 General Farnis - Livestock 

AGRICULTURAL SERVICES 

0711 Soil Preparation - Fertilizing, Plowing 

0721 Crop Planting, Cultivation & Protecting 

0722 Crop Harvesting - Machine 

FORESTRY 

0811 Timber Tracts - Christmas Trees, Tree Famis 

0831 Forest Nurseries 

0851 Forest Services 

0921 Fish Hatcheries 

DIVISION B - MINING 

tl/tlNlNG & QUARRYING 

1429 Crushed & Broken Stone 

1442 Constmction Sand & Gravel 

DIVISION C - CONSTRUCTION 

BUILDING CONSTRUCTION 

1521 General Contractors - Single Family Houses 

1522 Gen. Contractors - Residential 

1531 Operative Builders 

1541 Gen. Contractors - Industrial Buildings & Warehouses 

1542 Gen. Contractors - Nonresidential Buildings 

HEAVY CONSTRUCTION - NOT BUILDINGS 

1611 Hig hway & Street Construction 

1622 Bridge, Tunnels & Elevated Highways 

1623 Water, Sewer, Pipeline & Communications & Power Line Construction 

1

SPECIAL TRADE CONTRACTORS 

|711 Plumbing, Heating & Air Conditioning 

1721 Painting & Paper Hanging 

1731 Electrical Wori< 

1741 Masonry & $tonewori< 

1742 Plastering, Drywall & Insulation Wori< 

1743 Tile, Marbles Mosaic Wari< 

1751 Carpentry Wori< 

1752 Floors, Other 

1761 Roofing, Siding & Sheet Metal 

1771 Concrete Wori< 

1781 Water Well Drilling 

1791 Stmctural Steel Erection 

1793 Glass & Glazing 

1794 Excavation Wori< 

1795 Wrecking & Demolition 

1796 Installation Or Erection Of Building Equipment, Other 

1799 Special Trade Contractors, Other (Awning Installation, Dewatering Contractors, House 

Moving, Steeplejacks & Weather Stripping) 

DIVISION D - MANUFACTURING 

FOOD PRODUCTS 

•2021 Creamery Butter 

2022 Cheese 

2024 Ice Cream 

2026 Milk 

2032 Canned Specialties 

2033 Canned Emits, Vegetables & Presen/es 

2034 Dried Emits, Vegetables & Soups 

2035 Pickled Emits & Vegetables 

2037 Frozen Emits & Vegetables 

2041 Flour & Other Grain Mill Products 

2047 Dog & Cat Food 

2051 Bread & Bakery 

2082 Malt Beverages 

2084 Wines, Brandy & Brandy Spirits 

2085 Distilled & Blended Liquors 

2086 Soft Drinks 

LUti/IBER & WOOD PRODUCTS 

2411 Logging 

2421 Sawmills & Planing Mills 

2426 Hardwood Dimension & Flooring Mills 

2431 Millwori< 

2434 Wood Kitchen Cabinets 

2435 Hardwood Veneer & Plywood 

2436 Softwood Veneer & Plywood 

2448 Wood Pallets & Skids 

2452 Prefabricated Wood Buildings 

2491 Wood Preserving 

PAPER SALLIED PRODUCTS 

2611 Pulp Mills 

2621 Paper Mills 

2631 Papertjoard Mills 

2653 Cormgated Boxes 

2656 Sanitary Food Containers 

2673 Plastic, Foil & Coated Paper Bags 

2674 Uncoated Paper Bags 

PRtNTtNG. PUBLISHING, & ALLIED INDUSTRIES 

2711 Newspapers 

2721 Periodicals 

2731 Books 

2732 Book Printing 

2752 Commercial Printing - Lithographic 

2754 Commercial Printing - Gravure 

2761 Manifold Business Fonms 

2789 Bookbinding 

2791 Typesetting 

CHEMICALS i ALLIED PRODUCTS 

2812 Alkalies & Chlorine 

2813 Industrial Gases 

2816 Inorganic Pigments 

2819 Industrial Inorganic Chemicals, Other 

2821 Plastics 

2822 . Synthetic Rubber 

2833 Medicinal Chemicals & Botanical Products 

2834 Pharmaceutical Preparations 

2841 Soap & Other Detergents 

2842 - Cleaning, Polishing & Sanitation Preparations 

2851 ' Paints, Vamishes, Lacquers 

2869 Industrial Organic Chemicals 

2873 Nitrogenous Fertilizers 

2874 - Phosphatic Fertilizers 

2879 Pesticides 

January 2008 Page 5 of 11 DEQ-05-LQ-016A 
INDEX OF SELECT STANDARD INDUSTRIAL CODES 

2893 Printing Ink 

PETROLEUM REFINING & RELA TED INDUSTRIES 

2911 Peti-oleum Refining 

2951 Asphalt Paving Mixtures 

RUBBER S MISCELLANEOUS PLASTICS 

3011 Tires 

3084 Plastics Pipe 

3085 Plastics Bottles 

PRIMARY METAL INDUSTRIES 

3312 Steel Wori<s 

3321. Gray & Ductile Iron Foundries 

3334 Primary Production Of Aluminum 

3341 Secondary Smelting & Refining - Nonfen-ous 

3365 Aluminum Foundries 

3366 Copper Foundries 

DIVISION E -TRANSPORTATION, COMMUNICATIONS, ELECTRIC, GAS & 

SANITARY SERVICES 

RAILROAD TRANSPORTATION 

4011 Railroads, Line-Haul Operating 

4013 Railroad Swritching/Temiinals 

LOCAL TRANSIT & HIGHWAY PASSENGER TRANSPORTATION 

4111 Local & Suburban Transit 

4121 Taxicabs 

4131 Intercity & Rural Bus Transportation 

4151 School Buses 

4173 Terminal & Service Facilities 

MOTOR FREIGHT TRANSPORTA TION & WAREHOUSING 

4212 Local Trucking Without Storage 

4213 Tmcking, Not Local 

4214 Local Trucking With Storage 

4215 Courier Services 

4221 Earn Product Storage 

4222 Refrigerated Warehousing & Storage 

4225 General Warehousing & Storage 

4231 Tenninal & Maintenance Facilities - Freight Transportation 

4311 United States Postal Service 

4493 Marinas 

TRANSPORTA TION BY AIR 

4512 Air Transportation 

4513 Air Courier Services 

4581 Airports, Flying Fields & Terminals 

COMMUNICATIONS 

4812 Radiotelephone 

4813 Telephone 

4832 Radio Broadcasting Stations 

4833 Television Broadcasting Stations 

ELECTRIC, GAS S SANITARY SERVICES 

4911 Elecbic Services 

4923 Nafciral Gas Distiibution 

4941 Water Supply , 

4952 Sewerage Systems 

4953 Refuse Systems 

4971 Irrigation Systems 

DIVISION F - WHOLESALE TRADE 

DURABLE GOODS 

5014 Tires & Tubes v^ 

5031 Lumber, Plywood, Millwori^ & Wood Panels 

5082 Consfruction & Mining Equipment - Sold To Companies 

5083 Farni & Garden Machinery & Equipment - Sold To Famns & OUier Businesses 

5084 Industiial Machinery & Equipment - Sold To Companies 

5085 Industrial Supplies 

5093 Scrap & Waste Materials 

NONDURABLE GOODS 

5141 Groceries, General Line 

5142 Packaged Frozen Foods 

5143 Dairy Products 

5144 Poultry & Poulby Products 

5146 Fish 8i Seafood 

5147 Meats & Meat Products 

5148 Fresh Emits & Vegetables 

5171 Peti-oleum Bulk Stations & Terminals 

5172 Petroleum & Peft-oleum Products - Not Terminals 

5181 Beer & Ale 

5182 Wine & Distilled Alcoholic Beverages 

5191 Farni Supplies 

DIVISION G-RETAIL TRADE 

BUILDING MATERIALS, HARDWARE GARDEN SUPPLY S MOBILE HOME 

DEALERS 

5211 Lumber & Ottier Building Materials 

5251 Hardware Stores 

5261 Retail Nurseries, Lawn & Garden Supply Stores ) 

5271 Mobile Home Dealers 

GENERAL MERCHANDISE STORES 

5311 Department Stores 

5331 Variety Stores 

FOOD STORES 

5411 Grocery Stores ^ 

5431 Emit & Vegetable Mari^ets 

5451 Dairy Products Stores 

AUTOMOTICEDEALERS S GASOLINE SERVICE STA TIONS 

5511 Motor Vehicles Dealers (New & Used) 

5521 Motor Vehicles Dealers (Used Only) 

5531 Auto And Home Supply Stores 

5541 Gasoline Service Stations 

5561 Recreational Vehicle Dealers 

5571 Motorcycle Dealers 

EA TING & DRINKING PLACES 

5812 Eating Places 

5813 Drinking Places (Alcoholic Beverages) 

5983 Fuel Oil Dealers 

DIVISION H - FINANCE, INSURANCE & REAL ESTATE 

DEPOSITORY INSTITUTIONS 

6021 National Commercial Banks 

6022 State Commercial Banks 

6029 Ottier Commercial Banks 

6035 Savings Instihjtions, Federally Chartered 

6061 Credit Unions 

REAL ESTATE 

6512 Operators Of Nonresidential Buildings 

6513 Operators Of Apartment Buildings 

6515 Operators Of Residential Mobile Home Sites 

6531 Real Estate Agents & Managers 

6552 Land Subdividers & Developers 

DIVISION 1-SERVICES 

HOTELS ROOMING HOUSES CAMPS <S OTHER LODGING PLACES 

7011 Hotels & Motels - Including Recreation Facilities 

7032 Sporting & Recreational Camps 

7033 Recreational Vehicle Pari(s & Campsites - Campgrounds 

7216 Drydeaners 

AUTOMOTIVE REPAIR, SERVICES S PARKING 

7513 Tmck Rental & Leasing 

7514 Passenger Car Rental 

7515 Passenger Car Leasing 

7521 Automobile Paridng 

7532 Top, Body & Upholstery Repair Shops 

7534 Tire Retreading & Repair Shops 

7537 Automotive Transmission Repair Shops 

7538 General Automotive Repair Shops 

7542 Caiwashes 

7549 Lubricating Service & OUier Automotive Services, Except Repair/Canwashes 

AMUSEMENTS, RECREA TION SERVICES 

7992 Public Golf Courses 

7996 Amusement Paries 

7999 Amusement & Recreation Services, Ottier - Paries, Fairgrounds, Day Camps, Moped 

Rental, Ski Lifts, Tourist Atb-actions 

8062 General Medical & Surgical Hospitals 

5983 Fuel Oil Dealers 

EDUCATIONAL SERVICES 

8211 Elementary & Secondary Schools 

8221 Colleges, Universities & Professional Schools 

8231 Libraries 

8711 Engineering Services 

DIVISION J - PUBLIC ADMINISTRATION 

9111 Executive Offices—Offices Of Cities, Counties, Mayors, Etc. 

9121 Legislative Bodies—City Councils, County Commissioners, Etc. 

9199 General Govemment—OUier Govemment 

9221 Police Protection 

9223 Correctional Instihjtions 

9224 Fire Protection 

9512 Land, Mineral, Wildlife & Forest Conservation 

9621 Regulation & Administi-ation Of Transportati'onPrograms - Port Auttiorities 

January 2008 Page 6 of 11 DEQ-05-LQ-016A 
' ^ ^ 

^ 

DEQ 

Slate of OiBgon 

Department of 

Environmental 

Quality 

OREGON DEPARTMENT OF ENVIRONMENTAL QUALITY 

UNDERGROUND STORAGE TANK PROGRAM 

GENERAL PERMIT REGISTRATION FORM 

AND 30-DAY NOTICE 

FOR DEQ USE ONLY 

Date Rec'd 

CkNo. 

Amt Rec'd $ ' 

Deposit UST Permit Fees 

• . \ /'.•\\ -

'.- . W . • \ 

-=: y^ . 

FACILITY NAME: 

FACILITY ADDRESS: 

CITY, STATE & ZIP: 

PHONE: 

SIC CODE: 

FACILITY NUMBER: 

(If known) 

GENERAL PERMIT REGISTRATION FEE 

For new tanks, a registration fee of $135.00 per tank and an installation fee of $400 per 

tank is due for the current year. For multi-chambered or multi-compartment tanks, the 

registration fee is $135.00 and the installation fee is $400 for each chamber or 

compartment. To calculate the registration fee owed please fill in the blanks below: 

Number of new tanks or compartments X $535.00 = ^ Total Fee Due 

This registration fee will also serve as the first armual compliance fee for the remaining 

portion ofthe year in which the registration form is submitted. 

January 2008 Page 7 of 11 DEQ-05-LQ-016A 
GENERAL PERIMIT REGISTRATION FORIM 

TO INSTALL AND OPERATE USTs 

1. TAN K OWNER * as registered with 

the Secretary of State, Corporations Division 

Name of Official (Please Print) 

' • ' 1 • 

Signature of Official Date 

—1: = • —._^^- . - — 

Mailing Address (Please Print) 

City, State and Zip Code 

Area Code and telephone Number 

I will install and operate the USTs described on the Notification and Description of Underground Storage 

Tank Systems pages in accordance with the conditions and requirements ofthe applicable general permits. 

^ 2 . PERMITTEE * as registered with the 

Secretary of State, Corporations Division 

Name of Official (Please Print) 

Signature of Official Date 

....-.:;:.. . ' 

Mailing Address (Please Print) 

City, State and Zip Code 

Area Code and Telephone Number 

I will install and operate the USTs described on the Notification and Description of Underground Storage 

Tank Systems pages in accordance with the conditions and requirements of the ap^icable general permits. 

r .• . . " • 

3 . PROPERT Y OWNE R is name that 

appears on the County deed record for this property. 

f^ame of Official (Please Print) 

Signature of Official Date 

Mailing Address (Please Print) 

/ 

City, State and Zip Code 

Area Code and Telephone Number 

* If this facility or tanks are o-wned by a person, or operated by a permittee, that is a business registered with the 

Secretary of State, Corporations Division, please use that legal business name for purposes of registering these USTs 

with the Department. 

Please return completed pages 7 & 8, the Notification and Description of Underground Storage Tank Systems 

pages 9,10 and 11, and applicable registration fee to: 

DEQ - Business Office 

811 SW e"" Avenue 

Portland, Oregon 97204 

January 2008 Page 8 of 11 DEQ-05-LQ-016A 
Notification and Description of Underground Storage Tank Systems 

TYPE OF OWNER INDIAN COUNTRY 

I I Federal Government 

I : I State Government 

I I Local Government 

I I Commercial 

I I Private 

Tanks are located on land within an Indian I I 

Reservation or on trust lands outside ^~^ 

reservation boundaries. 

Tanks are owned by a Native American 

nation or tribe. 

D 

Tribe or Nation: 

TYPE OF FACILITY 

Gas Station 

Petroleum Distributor 

I I Air Taxi (Airline) 

I J Aircraft Owner 

I I Auto Dealership 

I I Railroad 

I I Federal - Non-Military 

I j Federal - Military 

D 

• 

Industrial 

Contractor 

I I Trucking/Transport 

I I Utilities 

I I Residential 

I I Farm 

I I Other (Explain) 

FINANCIAL RESPONSIBILITY 

n will meet the financial responsibility requirements 

in accordance with OAR 340 - Division 151 

Check All that Apply 

^ 1 Pollution Liability Insurance 

^ H j Self Insurance 

I Exempt (Federal or State Government) 

| _ J Letter of Credit 

I I Surety Bond 

I I Guarantee 

I I Local Government 

The financial responsibility requirements are designed to make sure that the tank owner, property owner or 

permittee can pay the costs of cleaning up leaks and compensating third parties for bodily injury and 

property damage caused by leaking USTs. A plain language summary ofthe financial responsibility 

requirements can be downloaded from the Internet at http://www.epa.gov/swerust1/pubs/dollars.htm. For a 

list of known insurance providers go to http://www.epa.gov/swerust1/pubs/inslist.htm. 

CONTACT PERSON IN CHARGE OF TANKS 

Name: Job Title: Address: Phone Number (Include Area Code): 

CERTIFICATION (Read and sign after completing all section) 

1 certify under penalty of law that 1 have personally examined and am familiar with the information submitted in this and all attached documents, and that based 

on my inquiry of those individuals immediately responsible for obtaining the information, 1 believe that the submitted information is true, accurate, and complete. 

Name and official title of owner or owner's 

authorized representative (Print) 

Signature Date Signed 

January 2008 Page 9 of 11 DEQ-05-LQ-016A 
NOTIFICATION AND DESCRIPTION OF UNDERGROUND STORAGE TANK SYSTEMS ^ 

(Complete for each tank at this location) ^ B 

Tank Identification Number 

Tank No. Tank No. Tank No. Tank No. Tank No. 

1. Status of Tank (Check (V) only one) 

Currently In Use 

Temporarily Ouliof Use 

Permanently Out of Use 

2. Date of Installation (month & year) 

3. Estimated Total capacity (gallons) 

4. Material of construction (Check (V) all 

Asphalt Coated or Bare Steel 

CathodicaUy Protected Steel, 

Epoxy Coated Steel 

Composite (Steel with Fiberglass) 

Fiberglass Reinforced Plastic 

Lined Interior 

Double Walled 

Polyethylene Tank Jacket 

Concrete 

Excavation Liner 

Unknown 

: Qthir IVIaterial, Pliase SpiBcify 

Has Tank been Repaired? 

Check (V) Box if Yes 

Date of Ripavii 

1 1 

1 : 1 

1 1 

1 1 

m«\. . . 1 

1 1 

.V- • i\ ; 

1 . 1 

1 1 

1 1 

1 1 

1 1 

1 1 

1 1 

1 ^^ •• 1^ ^^i1 1 

that apply) 

1 1 

1 

II 

II 

1 1 

^ \ 1 

1 

1 1 

1 

1 1 

1 1 

1 1 

1 • ••:•:•• ' .. y 

1 1 

N | - . ••,. 1 

1 1 1 V 1 

1 •:.••.••."i ! 

1 ^ :: m 

1 1 

5. Piping - Material (Check (V) all that apply) 

Bare Steel 

Bare Steel Wrapped 

Galvanized Steel 

Fiberglass Reinforced Plastic 

Copper 

CathodicaUy Protelted 

Double Walled 

Secondary containment 

Unknown 

Not in Contact With Soil 

Other Material, Please Specify 

6. Piping - Type (Check (V) all that apply 

Suction - no valve at tank 

Suction - valve at tank 

Pressure 

Gravity Feed 

Has Piping been Repaired? 

Check (V) box if Yes 

Date of Repair 

1 1 

1 1 

1 1 

1 1 

1 1 

1 1 

1 1 

1 1 

1 1 

1 1 

1 r 

1 1 " 

1 " 1 

1 1 

1 1 

1 1 

1 1 

1 M 

1 1 

1 1 

1 1 

1 1 

1 1 

:•:;:;•: ; : - | 

1 1 

1 • . !::;.•.. 

1 1 

I lA K 

1 1 

¥:'^".-::'. .-.I 

1 1 

1 1 

1 1 

1 1 

I I 

1 

1 1 

1 1 

1 1 

1 L. A 

• ^- • 

January 2008 Page 10 of 11 DEQ-05-LQ-016A 
NOTIFICATION AND DESCRIPTION OF UNDERGROUND STORAGE TANK SYSTEMS 

(Complete for each tank at this location) 

Tank Identification Number 

Tank No. Tank No. Tank No. Tank No. Tank No. 

7. Substance Currently or Last Stored in Greatest Quantity by Volume 

(Check (V) Only One Substance Per Tank) 

Gasoline 1 

Diesel J 

Gasohol 

Kerosene 

Heating Oil 

UsediDil 

Hazardous Substance 

CERCLA Name and/or 

CAS Number 

Mixture of Substances 

Please Specify Mixture 

Other 

Please Specify Other 

8. Release Detection (Check (V) all that Apply 

Manual Tank Gauging 

Tank Tightness Testing 

Inventory Control 

Automatic Tank Gauging 

Vapor Monitoring 

Groundwaterj-Mbnitoring 

Secondary Containment 

Automatic Line Leak Detector 

Line tightness Testing 

No Release Detection Required 

(Emergency Generator // Field Constmcted Tanks) 

Other Method Allowed by 

; Department 

Other Method, Please Specify 

9. Spill and Overfill Protection 

Overfill Device Installed 

Spill Device Installed 

January 2008 Page 11 of 11 DEQ-05-LQ-016A 

« 

9^ 

DEQ 

state of Oragon 

Department of 

Environmental 

Quality 

OREGON DEPARTMENT OF ENVIRONMENTAL QUALITY 

UNDERGROUND STORAGE TANK PROGRAM 

UST INSTALLATION CHECKLIST 

DEQ UST Facility ID #: 

DEQ Facility Address: 

_DEQ Facility Name: 

•Permittee Phone: 

This checklist must be filled out by the DEQ licensed UST Supervisor and submitted as part of the installation record in accordance 

with OAR Chapter 340 - Divisions 150 and 160. The UST Supervisor must be on-site during the field operations listed below. A new 

installation must be inspected a minimum of three times by the installer and all the requested information provided to the DEQ. 

Where a specific item is "NOT APPLICABLE" to the situation, please check the N/A box. This checklist must be signed by an 

executive officer of the UST Service Provider iirm and by the licensed UST Supervisor on page 6. The Permittee or tank owner 

must sign the certification statement on page 6. The last page of this checklist contains addresses and phone numbers for DEQ 

regional offices. 

FIRST INSPECTION - PRIOR TO PLACEMENT OF THE UNDERGROUND 

STORAGE TANK INTO THE EXCAVATION 

# 

1. The tank installer is licensed by DEQ as a UST Service Provider. 

2. Permittee has submitted the DEQ General Permit Registration Form to Install and 

Operate USTs 30-days prior to starting the installation with the aDnronriate general permit 

fees. Certificate number: -- • • ^^;: ' • :;^: :::• • "•'••'-'• •• • ' :••'•• '•' 

3. The DEQ Regional Office was notified 72 hours (3 working days) in advance ofthe 

installation. Notification log number: •:': ••: : ' ;: : ' :• • '; •' •.•':'.'• ' -^ 

4. Was hydrocarbon contammation observed? If so, was it reported to DEQ? Release log 

number: 

5. Tank and piping materials must comply with OAR Chapter 340 - 150 - 0160. 

6. Manufacturer's specifications for pre-mstallation practices have been followed. 

7. Any detected damage has either been repaired or replaced in a manufacturer-approved 

manner prior to placement in the excavation. 

8. Tanks have been pressure tested and satisfy API #1615 specifications. 

9. Tank excavation complies with the standards of API #1615 or PEI/RP 100-2000. 

10. Backfill and bedding materials fulfill the tank manufacturer's recommendations. 

11. Any required anchoring of tanks (full or empty) is in accordance with the manufacturer's 

specifications. 

12. The above requirements have been followed and hnplemented. 

1^'Inspection Date 

YES 

n 

'• r 

NO 

1 1 

Unknown 

1 1 

N/A 

Licensed UST Supervisor's Signature 

Print Name Supervisor's License Number 

January 2008 Page lo f 8 05-LQ-017A 
SECOND INSPECTION - AFTER PLACEMENT OF UNDERGROUND STORAGE 

TANK, BUT PRIOR TO BACKFILLING 

13. Tank placement was done in accordance with the manufacturer's specifications. 

14. Was tank damaged prior to or during placement? 

SACRIFICIAL ANODE SYSTEMS 

15. Did anodes, dielectric bushings, or coatings mcur any damage during installation? 

16. Damages to anode connections, coatings or tanks have been repau-ed in accordance with 

the manufacturer's specifications. 

17. Necessary pre-packing on each anode has been removed or kept intact according to 

manufacturer's instructions and/or each anode has been properly placed in its prepackaged 

- backfill material. 

IMPRESSED CURRENT SYSTEMS 

18. Were the anodes or the associated lead wires and msulation damaged during installation? 

19. Anodes have been mstalled according to the manufacturer's specifications. 

20. The negative terminal ofthe rectifier has been connected to the structure and the positive 

terminal to the anodes. 

21. Continuity of the wire has been tested. 

22. Was testing conducted to ensure that cathodicaUy protected structures have not been 

grounded in such a way that would nullify cathodic protection to the underground storage 

tank system? 

23. A cathodic protection test station is installed. 

PIPING 

24. Does all piping slope back (down) to the tanks? 

25. Piping joints have been assembled in accordance with the piping and sealant 

manufacturer's preparation, application and assembly instructions. 

26. All piping mstalhnent requirements specified by the manufacturer have been followed and 

implemented. 

YES 

r r ^ 

- : 

NO Unknown 

/ 

N/A 

m 

-)nd 

Licensed UST Supervisor's Signature 

2 Inspection Date 

Print Name Supervisor's License Number 

IMPORTANT 

ATTACH INFORMATION FOR ANY EQUIPMENT ASSOCIATED WITH THE UST SYSTEMS INSTALLED. THIS 

WILL INCLUDE AT A MINIMUM, A LIST OF MAJOR SYSTEM COMPONENTS, THIRD-PARTY EVALUATIONS, 

MANUFACTURERS CHECKLISTS, PHOTOGRAPHS, AS-BUILTS, AND IF AVAILABLE FIRE AUTHORITY 

SIGNOFF OR PRESSURE TEST RECORDS. 

January 2008 Page 2 of8 05-LQ-017A 
THIRD INSPECTION - AFTER BACKFILLING AND PRIOR TO OPERATION 

27. Backfill material and installation completed as per tank manufacturer's specifications. 

^28. All electrical equipment, wiring and related installations have been done in accordance 

with NFPA 70 and NACE RP 0285 - 2002. 

29. Piping has been pressure tested and satisfies API #1615 specifications. 

30. Spill protection devices have been properly installed. 

31. Was pipmg damaged during installation or backfilling? 

32. Non-corrosion resistant piping has been cathodicaUy protected. 

33. Pipe coating (if applicable) has all existing damage (holidays, chips, scratches, etc.) 

repaired in accordance with the manufacturer's specifications. 

34. Piping is electrically isolated fi'om dispensers, structures, tanks and other pipes or conduits. 

35. Piping has electrical continuity. 

38. Cathodic protection mstallation meets API #1632 or NACE RP 0285 - 2002 standards. 

36. Have dissimilar metals been connected together? 

37. All dielectric bushings and fittings are compatible with the liquid stored and the operating 

pressure ofthe tank system. 

38. Protection is provided for those gauges, monitoring devices, and other systems which, 

when subject to failure by corrosion, may cause a release or impair the operation of a 

monitoring system. 

39. Adequate clearance has been provided between piping and trench walls, conduit, 

monitoring well, utilities, nearby structures, and other system components following 

NFPA, API or PEI standards. 

40. Were there any leaks or evidence of leakage in the assembled piping at any connection of 

flexible connectors under either pressure testing or normal operating conditions? 

41. Both overfill protection and leak detection monitoring system requhements of OAR 340-

150-0160 have been met and are functioning properly. 

42. Tank deflection measurements for FRP tanks have been remeasured at this point and 

remain within the acceptable limits ofthe manufacturer's speciflcations. 

43. Cathodic protection systems tested and found to be providing adequate protection? 

44. Is a follow-up cathodic protection inspection scheduled or planned at the required interval? 

45. Intemal and extemal monitoring and gauging systems are working properly. 

46. One copy ofthe as built drawings ofthe mstallation is attached to this checklist. 

47. Major UST system cornponent list is attached. (May include receipts or invoices). 

48. A copy ofthe monitoring system third party evaluation is attached (May include a one 

page summary or the first page ofthe complete evaluation). 

49. Copies ofthe manufacturer's checklists are attached. 

50. Photographs attached. 

51. Fire authority signoff and or copies of pressure test results are attached. 

YES NO 

1 1 

Unknown 

• M 

N/A 

1-1 

1 

1 

Licensed UST Supervisor's Signature 

Print Name 

3^'* Inspection Date 

Supervisor's License Number 

January 2008 Page 3 of8 05-LQ-017A 
UST and Piping Equipment Information 

System # 

Tank Type 

Tank 

Manufacturer 

Tank 

Model # 

Product 

Volume, gal. 

Pipe Type 

Pipe 

Manufacturer 

Pipe 

Model # 

1 

• ' ; 

2 3 

•''' - - ^ • : :^ ; 

4 

UST Release Detection Equipment Information 

Check at least one Release Detection Method for each tank: 

Tank # 

Automatic Tank Gauging System 

Interstitial Monitoring (with secondary containment) 

Groundwater Monitoring ' 

Vapor Monitoring 

Inventory Control and Tank Tightness Testing 

Manual Tank Gauging Only 

Manual Tank Gauging and Tank Tightness Testing 

Other Release Detection Method, such as SIR (please specify) 

#1 #2 #3 #4 1 

Spill Prevention Equipment Information 

Tank # 

Spill Bucket 

Catchment Basin 

No Spill Prevention Requirement 

#1 #2 

• •-- • 

#3 .4 1 

January 2008 Page 4 of 8 05-LQ-017A 
Piping Release Detection Methods and Equipment 

ressurized Piping Methods 

heck at least one Release Detection method from Section A "AND" at least one method fi-om Section B for piping system: 

Section A 

Piping systems 

Automatic Line Leak Detector -Flow Restrictor (mechanical) 

Automatic Line Leak Detector-Flow Shutoff (electrical) 

Automatic Shutoff Device 

Sensor with Continuous Alarm 

#1 #2 #3 #4 1 

• • 

Section B 

Piping Systems 

Annual Line Tightness Test 

Monthly Monitoring* 

#1 

\ " ' 

#2 #3 .. #4 1 

# 

uction Piping Methods 

heck at least one Release Detection method s below: 

Piping Systems 

Lme Tighmess Testing Every Three Years 

Monthly Monitormg* 

No Release Detection Required For "Safe Suction" ** 

#1 #2 #3 #4 1 

* Monthly Monitoring for piping includes Interstitial Monitoring, Vapor Monitoring, Groundwater Monitoring, and SIR (not pressure). 

** No release detection required only if it can be verified that you have a "safe suction" piping system with the following characteristics: 

1) Only one check valve per line located directly below the dispenser; 

2) Piping sloping back to the tank; and 

3) System must operate under atmospheric pressure. 

Overfill Prevention Devices 

Check at least one Release Detection method s below: 

Tank# 

Overfill Alarm 

Automatic Shutoff Device 

Ball Float Valve 

No Overfill Prevention Required 

#1 

^Z:'\:Z 

mmm 

#2 #3 #4 1 

January 2008 Page 5 of8 05-LQ-017A 
INSTALLER'S OATH: I certify that I was the Oregon DEQ licensed supervisor present on site during the 

above listed tank installation activities and to the best of my knowledge they have been conducted in 

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

underground storage tanks. I further certify that the information contained in this report and checklist is true to 

the best of my belief and knowledge. 

Installer: 

(Print Name) (Signature) 

Position: 

Company: . Date: 

UST Service Provider Firm, Executive Officer: 

(Print Name) (Signature) (Date) 

PERMITTEE OR OWNER'S FINANCIAL RESPONSIBILirY INFORMATION SECTION: 

The permittee or tank owner has financial responsibility, if applicable, in accordance with 40 CFR Part 280 -

Subpart H as adopted pursuant to OAR 340-151-0015. Please specify the type of financial mechanism being 

used to comply with this requirement and submit a copy ofthe required documentation specified in the rules. 

NOTE: If pollution liability insurance is your mechanism of choice, you must submit a copy ofthe 

Certificate of Endorsement or Certificate of Insurance required by Section 280.97 (b)(1) or (b)(2), 

respectively. An ACORD does not satisfy the proof of insurance requirement. 

I I Permittee [ I Tank Owner Please check ('' ) who is providing financial responsibility. 

Method of financial responsibility: • ' ' • " -•. • • '••: •• :• -^ :-" : •' ' /^^i-v.:;'/ • •: 

Insurer: •• ' •: ': • ' Policy Number: ••• ' . / ./:. 

UST FACILITY PERMITTEE OR TANK OWNER 

INSTALLATION CERTIFICATION STATEMENT: 

I hereby certify that the information provided on this form concerning the installation status of my 

underground storage tank system(s) Is accurate. 

Print Name Signature (Tequired) Date 

Please note: In accordance with ORS 466.765 and OAR 340-150-0135 (2), you are required to cooperate fully with 

inspections, monitoring and testing conducted by the Department, as well as requests for document sutimisslon, testing 

and monitoring pursuant to section 9005 of Subtitle I of the Resource Conservation and Recovery Act, as amended. 

The Information you have submitted Is subject to audit and verification by the Department's Underground Storage Tank 

Compliance Inspectors. A false certification may result In enforcement action being taken by the Department. 

January 2008 Page 6 of 8 05-LQ-017A 
DEQ REGIONAL USE ONL Y UST FACILITY ID NUMBER:, 

DEQ REGIONAL INSPECTIONS AND REVIEW: This form may be used by DEQ Inspectors for 

oversight purposes. A DEQ inspector is not required to inspect the installation. A DEQ inspector may or may 

not be on site or available during all ofthe inspections listed on this form. In the case of an oversight 

inspection, the DEQ inspector should check all boxes that are appropriate for the inspection(s). This section of 

the form will be used by DEQ regional staff as verification of regional review. 

Checklist has been reviewed and is complete Initial 

Checklist attachments submitted and complete Initial 

Installer certification complete Initial . 

Full compliance inspection completed Yes No 

Partial compliance inspection completed Yes No 

Passed compliance inspection Yes No N/A_ 

Notes: 

DEQ Inspector: 

(Please Print) 

DEQ Inspector's Signature: Date: 

DEQ HQ STAFF USE ONLY 

This section ofthe form used as verification confirmation of financial responsibility. 

Check all that apply. 

Q Pollution Liability Insurance Q Letter of Credit G Guarantee 

Q Self Insurance Q Surety Bond Q Local Govemment 

Q Exempt (Federal or State Govemment) 

DEQ Staff Signature: Date:__ 

January 2008 Page 7 of 8 05-LQ-017A 
NORTHWEST REGION: 

Clackamas, Clatsop, 

Columbia, Multnomah, 

Tillamook & Washington 

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 

This form must be mailed to the appropriate DEQ Regional Office within 30 days after 

the installation is complete. For information, call the appropriate DEQ Regional Office or 

the toll free number 1-800-742-7878. 

THE DEPARTMENT OF ENVIRONMENTAL QUALITY UST PROGRAM 

REGIONAL OFFICE IN WHICH YOUR FACILITY IS LOCATED 

EASTERN REGION/THE DALLES 

400 E SCENIC DRIVE, # 307 

THE DALLES, OR 97058 

FAX: 541-298-7330 

Phone: 541-298-7255 

NORTHWEST REGION 

2020 SW 4TH AVENUE, SUITE 400 

PORTLAND, OR 97201 

FAX: 503-229-6945 

Phone: 503-229-5263 

WESTERN REGION/ COOS BAY 

381 N. SECOND STREET 

COOS BAY, OR 97420 

FAX: 541-269-7984 

Phone: 541-269-2721 

WESTERN REGION / EUGENE 

1102 LINCOLN STREET, SUITE 210 

EUGENE, OR 97401 

FAX: 541-686-7551 

Phone: 541-686-7838 

UST HELPLINE: 1-800-742-7878 

(Toll Free in Oregon) 

WESTERN REGION / SALEM 

750 FRONT STREET NE, SUITE 120 

SALEM, OR 97301 

FAX: 503-373-7944 

Phone: 503-378-8240 

\ 

J 

January 2008 Page 8 of8 05-LQ-017A 
^o^ 

state of Oregon 

Department of 

Environmental 

Quality 

OREGON DEPARTMENT OF ENVIRONMENTAL QUALITY 

UNDERGROUND STORAGE TANK PROGRAM 

GENERAL PERMIT REGISTRATION FORM 

AND 30-DAY NOTICE 

• 

Complete one general permit registration package for each separate 

facility you are registering. 

Each registration package includes the registration form (pages 7 & 8) with 

signature blocks, a fee matrix to calculate the required registration fee 

(page 7) and the notification and description of underground storage tank 

systems (pages 9, 10 & 11). 

If you are installing more than five (5) tanks, please make additional 

copies ofthe description pages (pages 9, 10 &. 11) and list the additional 

tanks on the copies you make. 

You must call your regional office to receive authorization to proceed with 

the Installation 72 hours prior to beginning work. See page 4 for office 

locations. 

CHECKLIST 

^ Be sure signatures are provided for the tank owner, permittee and property owner, 

even where one person fills all three roles. 

^ Complete the registration form (pages 7 and 8) and the notification and description of 

underground storage tank systems (pages 9, 10 & 11) for all tanks being installed at 

the facility. 

>^ Make copies for your records. 

^ Enclose your check payable to: 

Oregon Department of Environmental Quahty 

^ Retum the general pemiit registration form (pages 7 and 8), the notification and 

description of imderground storage tank systems (pages 9, 10 & 11) and the correct 

total fee amount to: 

DEQ 

Business Office 

811 SW 6*''Avenue 

Portland, Oregon 97204 

January 2008 Page lof 11 DEQ-05-LQ-016A 
GENERAL INFORMATION PAGE 

DESCRIPTION OF GENERAL PERMIT PROGRAM 

In lieu of issuing individual permits, Oregon's UST permitting program has adopted general 

permits by rule as follows: 

. General Permit to Install (OAR 340-150-0160): this rule identifies the conditions and 

requirements that cover the construction of an UST system. 

General Perinit to Operate (OAR 340-150-0163): this rule identifies the conditions and 

requirements that covers the operation of an UST system that meets the performance 

standards for new or upgraded facilities. Facilities registering for a general permit to 

operate are authorized to deposit a regulated substance such as motor fuel into an UST. 

By signing the registration forms, you are certifying that you will comply with all the conditions 

and requirements ofthe general permits to install and operate. Upon receipt ofthe completed 

registration forms, the Department will issue a Registration Certificate to Install. This certificate 

does not authorize fuel delivery. To receive a Certificate to Operate authorizing fuel delivery 

you must submit to your DEQ regional office the following documentation: 

1. UST Installation Checklist, 

2. Information associated with the equipment installed including a list of major system 

components, third-party evaluations, manufacturers' checklists, photographs and fire 

authority sign-off, if available. 

When you receive your Certificate to Operate you must provide the Operating Certificate Number 

to your fuel distributor so they can deliver product to your facility. 

DEFINITIONS 

Install - means the physical construction of all or part of an underground tank, including but not 

limited to, activities such as excavating; backfilling; testing; proper placement of tank, piping, 

release detection devices, corrosion protection systems, spill and overfill devices and any 

associated administrative activities such as notifications, recprd keeping and record submissions. 

Operate - means depositing a regulated substance into, storing a regulated substance in or 

dispensing a regulated substance from an underground storage tank and such other activities, 

including but not limited to, performing release detection, maintaining corrosion control, 

preventing spills and overfills, investigating and confirming suspected releases, conducting 

maintenance, modifications, replacement and repairs of equipment, maintaining financial 

responsibility and submitting records on the UST and underground piping's performance. 

Owner - means a person who currently owns an UST or owned an UST during the operational 

life ofthe tank. If registered with the Secretary of State, Corporations Division, the tank owner is 

the legal business name. 

Permittee - means the owner or person designated by the owner, who is in control or has 

responsibility for daily UST system operation and maintenance, financial responsibility and UST 

operator training requirements under a general permit pursuant to OAR 340-150-0160 through 

340-150-0168. If registered with the Secretary of State, Corporations Division, the permittee is 

the legal business name. The permittee is mailed the annual compliance fee invoice. 

Property Owner - means the legal owner ofthe real property on which an UST is located (the 

name that appears on the County deed records). 

Registration Certificate - the document the Department issues to acknowledge receipt of a 

general permit registration form. The registration certificate to operate authorizes delivery of 

regulated substances, including motor fiiels. The registration certificates to install, decommission 

or manage a system in temporaty closure do not authorize product deliveries. 

SIC Code - Standard Industrial Code (see pages 5 & 6) 

January 2008 Page 2 of 11 DEQ-05-LQ-016A 

^ 

8 

i 
# 

INSTRUCTION PAGE 

TANKS REQUIRING A GENERAL PERMIT REGISTRATION 

FORM 

1. All underground tanks, including emergency generator tanks, containing petroleum products or listed 

chemicals, which are not exempt (examples are gasoline, diesel, industrial solvents, pesticides and 

herbicides). 

2. Tanks and piping with 10% or more of their total volume beneath the ground. 

3. Farm or residential motor fuel underground tanks larger than 1,100 gallons in capacity. 

4. Tanks containing regulated substances and not permanently decommissioned prior to May 1, 1988. 

EXEMPT TANKS (GENERAL PERMIT REGISTRATION NOT 

REQUIRED) 

1. Farm or residential motor fuel tanks of 1,100 gallon capacity or less. 

2. Heatittg oil tanks used for heat on the same property where the tanks are located. 

3. Septic Tanks. 

4. Pipeline Facilities. 

5. Surface hnpoundments. 

6. Storm Water or Waste Water Collection Systems 

7. Flow-Through Process Tanks. 

8. Liquid Traps. 

9. Tanks that are above the surface ofthe floor in an underground area. 

GENERAL PERMIT REGISTRATION FORM 

1. Please fill in the name, address and phone number ofthe facility, hiclude the Facility ID number if 

this form is being submitted for an existing facility that has previously registered other tanks. 

2. Please provide the SIC code for each facility (See pages 5 and 6). 

3. For new tanks, a registration fee of $135.00 per tank and an installation fee of $400 per tank are due 

for the cuirent year. For multi-chambered or multi-compartment tank, the registration fee is $135.00 

and the installation fee $400 for each chamber or compartment. Please fill in the number of new tanks 

or compartments in the space provided in the general permit registration fee section. Multiply this 

number by $535 to calculate the total amount owed. 

4. Please fill ia the tank owner's legal name, address and phone number. The legal name is the name of 

the tank owner as filed with the Secretary of State, Corporations Division, if applicable. The tank 

owner must sign the registration form. 

5. The tank owner can name a permittee for each facility. Please ask the pennittee in charge ofthe 

facility to fill in their legal name, address and phone number. The legal name is the name ofthe 

permittee as filed with the Secretary of State, Corporations Division, if applicable. The permittee must 

sign the registration form. 

6. Please fill in the property owner's name, address and phone number. The property owner's name 

should be the name in the county deed records. The property owner must sign the registration form. 

7. There must be three signatures for each completed registration form - the tank owner, permittee and 

property owner. IF ONE PERSON FILLS ALL THREE ROLES, THAT PERSON MUST SIGN 

THREETIMES. 

8. Complete pages 9, 10 and 11, Notification and Description of Underground Storage Tank Systems. 

LICENSED SERVICE PROVIDERS AND SUPERVISORS 

ORS 466.750 and OAR Chapter 340, Division 160 requires that licensed service providers perform tank 

installation work. NOTE: AN OWNER OR PERMITTEE MAY PERFORM UST SERVICES ONLY 

IF THEY HAVE TAKEN AND PASSED THE APPROPRIATE UST SUPERVISOR 

EXAMINATION OFFERED BY A NATIONAL TESTING SERVICE (OAR 340-150-0156). During 

certain critical phases as specified in the rules, a licensed supervisor must be present on site to monitor the 

work. Lists of hcensed service providers and supervisors are available upon request by calling (503) 229-

6652 or toll-free in Oregon 1-800-742-7878 (a message answering machine). 

January 2008 Page 3 of 11 DEQ-05-LQ-016A 
INSTRUCTION PAGE 

UST SYSTEM OPERATOR REQUIRED 

The owner or permittee of each UST facility issued an operating certificate that dispenses a regulated 

substance from an UST to a motor vehicle or container must employ trained personnel who can 

properly operate and maintain the UST system and provide emergency response information to any person 

that dispenses a regulated substance from the UST system. For more details on implementing this 

requirement see rule OAR 340-150-0200 or go to http://www.deq.state.or.us/lq/training.htm#trauiuig. 

HELP WITH THIS REGISTRATION FORM 

If you have any questions about this regisfration form, please phone the DEQ UST Program at (503) 229-

6652. You can also phone the UST Program's toll-free number, 1-800-742-7878. This is a message 

answering machine for calls made withia Oregon. Underground Storage Tank Program staff will retum 

your calls within 24 hours. You can also send an e-mail to tanks.info@deq.state.or us. Our regional 

staff are also available to answer questions regarding the general pennit program and this general permit 

regisfration form (see below for telephone numbers). 

COPIES OF GENERAL PERMIT CONDITIONS AND 

REQUIREMENTS AM) UST PROGRAM RULES 

Copies ofthe general permit to iastall and operate conditions and requirements and UST Program rules and 

laws can be obtained from: 

1. Any of the DEQ offices listed below, 

2. By calling the UST HELPLINE at 1-800-742-7878, 

3. Send an e-mail to tanks.info@.deq.state.or.us or 

4. Downloading from the UST home page at: 

http://www.deq.state.or.us/Iq/tanks/ust/mdex.htm 

^ 

NORTHWEST REGION 

Clackamas, Clatsop, 

Columbia, Multnomah 

Tillamook & Washington 

Counties 

WESTERN REGION: Benton, 

Coos, Cuny, 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 

Phone: 541-298-7255 

NORTHWEST REGION / PORTLAND 

- Phone:503-229-5263 

WESTERN REGION / COOS BAY 

Phone: 541-269-2721 

WESTERN REGION / EUGENE 

Phone: 541-686-7838 

UST HELPLINE (IN OREGON): 

WESTERN REGION / SALEM 

Phone: 503-378-8240 

1-800-742-7878 

^ . 

January 2008 Page 4 of 11 DEQ-05-LQ-016A 
INDEX OF SELECT STANDARD INDUSTRIAL CODES 

STANDARD INDUSTRIAL CODES FOR UNDERGROUND STORAGE 

TANKS 

he Standard Industrial Classification (SIC) Code was developed by the Federal 

'Government to aid in gathering econonnic statistics and to help compare information from 

different govemment agencies. The Department of Environmental Quality (DEQ) uses SIC 

codes to analyze underground storage tank locations and to Identify the businesses that 

own tanks. 

•

' • 

# 

SIC codes define industries according to their economic stnjcture. They classify businesses 

by their main activities and other measures of economic activity. (These SIC codes are NOT 

the same as those used on tax fornis. Please refer to this list for the correct SIC code). 

DEQ has detemnined that this list of SIC codes will describe many of the businesses that 

have underground storage tanks in Oregon. If your business is not listed, the complete list of 

SIC codes can be found in the reference section of your local library in the "Standard 

Industrial Classification Manual' for 1987. Please use the 1987 manual since it lists the 

con'ect, revised SIC codes. 

Please use the FOUR digit code that describes the main activity of your business. Find the 

correct division, being careful when selecting manufacturing, wholesale or retail. (There are 

similar codes in each of these categories.) Then find the major group that describes your 

business. The FOU/? digit code should be listed within that major group. For assistance, 

please contact the UST Compliance Section, (503) 229-6652. 

DIVISION A - AGRICULTURE, FORESTRY & FISHING 

CROPS 

0111 Wheat-Cash Grains 

0139 Field Crops - Alfalfa, Clover, Grass Seed, Hops 

0161 Vegetables And Melons 

0172 Grapes 

0173 Tree Nuts - Filberts, Walnuts 

0175 Deciduous Tree Fruits - Apples, Apricots, Cherries, Peach, Pear, Plum, Prune 

0181 Ornamental Floriculture & Nursery Products 

0182 Food Crops Grown Under Cover - Bean Sprouts, Greenhouses, Mushrooms 

0191 General Famis - Crops 

LIVESTOCK 

0211 Beef Cattle - Feedlots 

1212 Beef Cattle, Except Feedlots 

i213 Hogs 

1214 Sheep & Goats 

1219 General Livestock, Except Dairy & Poultry 

0241 , Dairy Farms 

0251 Broiler, Fryer & Roaster Chickens 

0252 Chicken Eggs 

0253 Turi<eys 8, Turkey Eggs 

0254 Poulty Hatcheries 

0279 Animal Specialties - Other (Bee Farms, Cat Farms, Dog Farms, Honey Production) 

0291 General Famns - Livestock 

AGRICULTURAL SERVICES 

0711 Soil Preparation - Fertilizing, Plowing 

0721 Crop Planting, Cultivation & Protecting 

0722 Crop Harvesting - Machine 

FORESTRY 

0811 Timber Tracts - Christmas Trees, Tree Farms 

0831 Forest Nurseries 

0851 Forest Services 

0921 Fish Hatcheries 

DIVISION B - MINING 

MINING & QUARRYING . 

1429 Crushed & Broken Stone 

1442 Construction Sand & Gravel 

DIVISION C - CONSTRUCTION 

BUILDING CONSTRUCTION 

1521 General Contractors - Single Family Houses 

1522 Gen. Contractors - Residential 

1531 Operative Builders 

1541 Gen. Contractors - Industrial Buildings & Warehouses 

1542 Gen. Contractors - Nonresidential Buildings 

HEAVY CONSTRUCTION-NOT BUILDINGS 

1611 Highway & Street Construction 

1622 Bridge, Tunnels & Elevated Highways 

1623 Water, Sewer, Pipeline 8i Communications & Power Une Construction 

SPECIAL TRADE CONTRACTORS 

711 Plumbing, Heating & Air Conditioning 

1721 Painting & Paper Hanging 

1731 Electrical Worit 

1741 Masonry & Stonewori( 

1742 Plastering, Drywall & Insulation Work 

1743 Tile, Martjie & Mosaic Wori< 

1751 Carpentry Work 

1752 Floors, Other 

1761 Roofing, Siding & Sheet Metal 

1771 Concrete Work 

1781 Water Well Drilling 

1791 Structural Steel Erection "^ 

1793 Glass 8i Glazing 

1794 Excavafon Work 

1795 Wrecking & Demolition 

1796 Installation Or Erection Of Building Equipment, Other 

1799 Special Trade Contractors, Other (Awning Installation, Dewatering Contractors, House 

Moving, Steeplejacks & Weather Stripping) 

DIVISION D - MANUFACTURING 

FOOD PRODUCTS 

2021 Creamery Butter 

2022 Cheese 

2024 Ice Cream 

2026 Milk 

2032 Canned Specialties 

2033 Canned Emits, Vegetables & Preserves 

2034 Dried Fruits, Vegetables 8i Soups 

2035 Pickled Fruits & Vegetables 

2037 Frozen Fmits & Vegetables 

2041 Flour & Other Grain Mill Products 

2047 Dog & Cat Food 

2051 Bread & Bakery 

2082 Malt Beverages 

2084 Wines, Brandy & Brandy Spirits 

2085 Distilled & Blended Liquors 

2086 Soft Drinks 

LUMBER & WOOD PRODUCTS 

2411 Logging 

2421 Sawmills & Planing Mills 

2426 Hardwood Dimension & Flooring Mills 

2431 Millwori( 

2434 Wood Kitchen Cabinets 

2435 Hardwood Veneer & Plywood 

2435 Softwood Veneer & Plywood 

2448 Wood Pallets & Skids 

2452 Prefabricated Wood Buildings 

2491 Wood Preserving 

PAPER SALLIED PRODUCTS 

2611 Pulp Mills 

2621 Paper Mills 

2631 . Paperboard Mills 

2653 Corrugated Boxes 

2656 Sanitary Food Containers 

2673 Plastic, Foil & Coated Paper Bags 

2674 Uncoated Paper Bags 

PRINTING, PUBLISHING, S ALLIED INDUSTRIES 

2711 Newspapers 

2721 Periodicals 

2731 Books 

2732 Book Printing 

2752 Commercial Printing - Lithographic 

2754 Commercial Printing - Gravure 

2761 Manifold Business Forms 

2789 Bookbinding 

2791 Typesetting 

CHEMICALS S ALLIED PRODUCTS 

2812 Alkalies & Chlorine 

2813 Industrial Gases 

2816 Inorganic Pigments 

2819 Industrial Inorganic Chemicals, Other 

2821 Plastics 

2822 Synthetic Rubber 

2833 Medicinal Chemicals & Botanical Products 

2834 Phannaceutical Preparations 

2841 Soap & Other Detergents 

2842 Cleaning, Polishing & Sanitation Preparations 

2851 ' Paints, Vamishes, Lacquers 

-2869 Industrial Organic Chemicals 

2873 Nitrogenous Fertilizers 

2874 Phosphatic Fertilizers 

2879 Pesticides 

January 2008 Page 5 of 11 DEQ-05-LQ-016A 
INDEX OF SELECT STANDARD INDUSTRIAL CODES 

2893 Printing Ink 

PETROLEUM REFINING S RELA TED INDUSTRIES 

2911 Petroleum Refining 

2951 Asphalt Paving Mixtures 

RUBBERS MISCELLANEOUS PLASTICS 

3011 Tires ' 

3084 Plastics Pipe 

3085 . Plastics Bottles 

PRIMARY METAL INDUSTRIES 

3312 Steelworks 

3321 . Gray & Ductile Iron Foundries 

3334 Primary Production Of Aluminum 

3341 Secondary Smelting & Refining - Nonfen-ous 

3365 Aluminum Foundries 

3366 Copper Foundries 

DIVISION E -TRANSPORTATION, COMMUNICATIONS, ELECTRIC, GAS & 

SANITARY SERVICES 

RAILROAD TRANSPORTATION 

4011 Railroads, Line-Haul Operating 

4013 Railroad Switching/Terminals 

LOCAL TRANSrrs HIGHWA YPASSENGER TRANSPORTA TION 

4111 Local & Suburban Transit 

4121 Taxicabs 

4131 Intercity & Rural Bus Transportation 

4151 School Buses 

4173 TenriinaiS Service Facilities 

MOTOR FREIGHT TRANSPORTA TION S WAREHOUSING 

4212 Local Tmcking Without Storage 

4213 Tmcking, Not Local 

4214 Local Tmcking With Storage 

4215 Courier Services 

4221 Farm Product Storage 

4222 Refrigerated Warehousing & Storage 

4225 General Warehousing & Storage 

4231 Tenninal & Maintenance Facilities - Freight Transportation 

4311 . United States Postal Service 

4493 Marinas 

TRANSPORTATION BY AIR 

4512 Air Transportation 

4513 Air Courier Services 

4581 Airports, Flying Fields & Tenninals 

COMMUNICATIONS 

4812 Radiotelephone 

4813 Telephone 

4832 Radio Broadcasting Stations 

4833 Television Broadcasting Stations 

ELECTRIC, GAS S SANITARY SERVICES 

4911 Electric Services 

4923 Natural Gas Distribution 

4941 Water Supply 

4952 Sewerage Systems 

4953 Refuse Systems 

4971 Irrigation Systems 

DIVISION F -WHOLESALETRADE 

DURABLE GOODS 

5014 Tires & Tubes 

5031 Lumber, Plywood, Millwori( & Wood Panels 

5082 Construction & Mining Equipment - Sold To Companies 

5083 Fami & Garden Machinery & Equipment - Sold To Farms & Other Businesses 

5084 Industtial Machinery & Equipment - Sold To Companies 

5085 Industrial Supplies 

5093 Scrap & Waste Materials 

NONDURABLE GOODS 

5141 Groceries, General Line 

5142 Packaged Frozen Foods 

•5143 Dairy Products 

5144 Poultry & Poultry Products 

5146 Fish & Seafood 

5147 Meats & Meat Products 

5148 Fresh Fmits & Vegetables 

5171 Petroleum Bulk Stations & Tenninals 

5172 Petroleum & Petroleum Products - Not Terminals 

5181 Beers Ale 

5182 Wine & Distilled Alcoholic Beverages 

5191 Fann Supplies 

DIVISION G-RETAIL TRADE 

BUILDING MA TERIALS HARDWARE GARDEN SUPPL Y S MOBILE HOME 

DEALERS 

5211 Lumber & Other Building Materials 

5251 Hardware Stores 

5261 Retail Nurseries, Lawn & Garden Supply Stores 

5271- Mobile Home Dealers 

GENERAL MERCHANDISE STORES 

5311 Department Stores 

5331 Variety Stores 

FOOD STORES 

5411 Grocery Stores 

5431 Emit & Vegetable Mari(ets 

5451 Dairy Products Stores 

AUTOMOTICE DEALERS S GASOLINE SERVICE STATIONS 

5511 Motor Vehicles Dealers (New & Used) 

5521 Motor Vehicles Dealers (Used Only) 

5531 Auto And Home Supply Stores 

5541 Gasoline Sen/ice Stations 

5551 Recreational Vehicle Dealers 

5571 Motorcycle Dealers 

EATINGS DRINKING PLACES 

5812 Eating Places 

5813 Drinking Places (Alcoholic Beverages) 

5983 Fuel Oil Dealers 

DIVISION H - FINANCE, INSURANCE & REAL ESTATE 

DEPOSITORY INSTITUTIONS 

6021 National Commercial Banks 

6022 State Commercial Banks 

6029 Other Commercial Banks 

6035 Savings Institutions, Federally Chartered 

6061 Credit Unions 

REAL ESTATE 

6512 Operators Of Nonresidential Buildings 

6513 Operators Of Apartment Buildings 

6515 Operators Of Residential Mobile Home Sites 

6531 Real Estate Agents & Managers 

6552 Land Subdividers & Developers 

DIVISION I - SERVICES 

HOTELS ROOMING HOUSES CAMPS S OTHER LODGING PLACES 

7011 Hotels & Motels - Including Recreation Facilities 

7032 Sporting & Recreational Camps 

7033 Recreational Vehicle Parits & Campsites - Campgrounds 

7216 Drydeaners 

AUTOMOTIVE REPAIR, SERVICES S PARKING 

7513 Tmck Rental & Leasing 

7514 . Passenger Car Rental 

7515 Passenger Car Leasing 

7521 Automobile Paridng 

7532 Top, Body & Upholstery Repair Shops 

7534 Tire Retreading & Repair Shops 

7537 Automotive Transmission Repair Shops 

7538 General Automotive Repair Shops 

7542 Can«ashes 

7549 Lubricating Service 8i Other Automotive Services, Except Repair/Carwashes 

AMUSEMENTS RECREA TION SERVICES 

7992 Public Golf Courses 

7996 Amusement Parits 

7999 Amusement & Recreation Services, Other - Pari<s, Fairgrounds, Day Camps, 

Rental, Ski Lifts, Tourist Attractions 

8062 General Medical & Surgical Hospitals . 

5983 Fuel Oil Dealers 

EDUCATIONAL SERVICES 

8211 Elementary & Secondary Schools 

8221 Colleges, Universities & Professional Schools 

8231 Libraries 

8711 Engineering Services 

DIVISION J - PUBLIC ADMINISTRATION 

9111 Executive Offices—Offices Of Cities, Counties, Mayors, Etc. 

9121 Legislative Bodies—City Councils, County Commissioners, Etc. 

9199 General Govemment—Other Govemment 

9221 Police ProtecBon 

9223 Con-ectional Instihjtions 

9224 - Fire Protection 

9512 Land, Mineral, Wildlife & Forest Conservation 

9621 Regulation & Administration Of Transportation'Programs - Pott Auttiorities 

n 

Q 

Moped 

i 

January 2008 Page 6 of 11 DEQ-05-LQ-016A 
state of Otegon 

Departmerrt of 

Environmental 

Quanty 

OREGON DEPARTMENT OF ENVIRONMENTAL QUALITY 

UNDERGROUND STORAGE TANK PROGRAM 

GENERAL PERMIT REGISTRATION FORM 

AND 30-DAY NOTICE 

FOR DEQ USE ONLY 

Date Rec'd 

CkNo. 

Amt Rec'd $ 

Deposit UST Permit Fees 

y j ] 

•..^; Le.Vi--. vi--- h'-^^r-.''- :i i--::UJ J_i >>"U-.; Nj . N\i ^ 

! iffiil. ASS IHMtBIlP 

FACILITY NAME: 

FACILITY ADDRESS: 

CITY, STATE & ZIP: 

PHONE: 

SIC CODE: 

FACILITY NUMBER: 

(If known) 

GENERAL PERMIT REGISTRATION FEE 

* 

For new tanks, a registration fee of $135.00 per tank and an installation fee of $400 per 

tank is due for the current year. For multi-chambered or multi-compartment tanks, the 

registration fee is $135.00 and the installation fee is $400 for each chamber or 

compartment. To calculate the registration fee owed please fill in the blanks below: 

Number of new tanks or compartments X $535.00 0 Total Fee Due 

This registration fee will also serve as the fijst annual compliance fee for the remairdng 

portion ofthe year in which the registration form is submitted. 

January 2008 Page 7 of 11 DEQ-05-LQ-016i^ 
GENERAL PERMIT REGISTRATION FORM 

TO INSTALL AND OPERATE USTs 

1. TAN K OWNER * as registered with 

the Secretary of State, Corporations Division 

Name of Official (Please Print) 

Signature of Official Date 

Mailing Address (Please Print) 

City, State and Zip Code 

Area Code and Telephone Number 

I will install and operate the USTs described on ihQ Notification and Description of Underground Storage 

Tank Systems pages in accordance with the conditions and requirements ofthe applicable general pennits. 

2 . PERMITTEE * as registered with the 

Secretary of State, Corporations Division 

Name of Official (Please Print) 

Signature of Official Date 

Mailing Address (Please Print) 

City, State and Zip Code 

Area Code and Telephone Number 

I will install and operate the USTs described on the Notification and Description of Underground Storage 

Tank Systems pages in accordance with the conditions and requirements ofthe applicable general permits. 

3 . PROPERT Y OWNE R is name that 

appears on the County deed record for this property. 

Name of Official (Please Print) 

Signature of Official - - - Date 

Mailing Address (Please Print) 

City, State and Zip Code 

Area Code and Telephone Number 

* If this facility or tanks are owned by a person, or operated by a permittee, that is a business registered with the 

Secretary of State, Corporations Division, please use that legal business name for purposes of registering these USTs 

with the Department. 

Please return completed pages 7 & 8, the Notification and Description of Underground Storage Tank Systems 

pages 9,10 and 11, and applicable registration fee to: 

DEQ - Business Office 

811 SW 6** Avenue 

Portland, Oregon 97204 

d 

^ 

January 2008 Page 8 of 11 DEQ-05-LQ-016A 
Notification and Description of Underground Storage Tank Systems 

'ft TYPE OF OWNER INDIAN COUNTRY 

Federal Government 

I • I State Government 

I I Local Government 

I I Commercial 

I I Private 

Tanks are located on land v\/ithln an Indian I I 

Reservation or on trust lands outside — 

reservation boundaries. 

Tanks are owned by a Native American 

nation or tribe. 

B 

Tribe or Nation: 

TYPE OF FACILITY 

I I Gas Station 

I I Petroleum Distributor 

I I Air Taxi (Airline) 

I J Aircraft Owner 

J Auto Dealership 

I I Railroad 

I I Federal - Non-Military 

I I Federal - Military 

I J Industrial 

I I Contractor 

I I Trucking/Transport 

n n utilities 

I I Residential 

I I Farm 

I I Other (Explain) 

FINANCIAL RESPONSIBILITY 

• I will meet the financial responsibility requirements 

in accordance with OAR 340 - Division 151 

Check All that Apply 

j . J Pollution Liability Insurance 

^ ^ ^ Self Insurance 

^^F J Exempt (Federal or State Government) 

L 

I I Letter of Credit 

I I Surety Bond 

I I Guarantee 

I ;: I Local Government 

The financial responsibility requirements are designed to make sure that the tank owner, property owner or 

permittee can pay the costs of cleaning up leaks and compensating third parties for bodily injury and 

property damage caused by leaking USTs. A plain language summary ofthe financial responsibility 

requirements can be downloaded from the Internet at http://www.epa.gov/swerust1/pubs/dollars.htm. For a 

list of known insurance providers go to http://www.epa.gov/swerust1/pubs/inslist.htm. 

CONTACT PERSON IN CHARGE OF TANKS 

Name: Job Title: Address: Phone Number (include Area Code): 

CERTIFICATION (Read and sign after completing all section) 

I certify under penalty of law that I have personally examined and am familiar with the Information submitted in this and all attached documents, and that based 

on my inquiry of those individuals immediately responsible for obtaining the infonnation, I believe that the submitted information is true, accurate, and complete. 

Name and official title of owner or owner's 

authorized representative (Print) 

kSignature Date Signed 

January 2008 Page 9 of 11 DEQ-05-LQ-016A 
NOTIFICATION AN D DESCRIPTION OF UNDERGROUND STORAGE TANK SYSTEMS ^ 

(Complete for each tank at this location) fi^ 

Tank Identification Number 

Tank No. Tank No. Tank No. Tank No. TankNi ^ 

1. Status of Tank (Check (V) onl y one) 

Currently In Use 

Temporarily Out of Use 

Permanently Out of Use 

2. Date of Installation (month & year) 

3. Estimated Total capacity (gallons) 

4. Material of construction (Check (V) all 

Asphalt Coated or Bare Steel 

CathodicaUy Protected Steel 

Epoxy Coated Steel 

Composite (Steel with Fiberglass) 

Fiberglass Reinforced Plastic 

Lined Interior 

Double Walled 

Polyethylene Tank Jacket 

Concrete 

Excavation Liner 

Unknown 

Other Material, Please Specify 

Has Tank been Repaired? 

Check (V) Box if Yes 

Date of Repair 

\ \ 

\ • Iil l 

1 1 

1 1 

1 - lliiii 

1 1 

1 1 

L_ |iii iiiii" 

1 1 

1 1 

1 1 

1 1 

1 ^^ iiiii 

1 1 

that apply) 

1 1 

1 iHlik 

1 1 

1 ••Iil l 

1 1 

1 Iiiil 

1 1 

1 liiiii 

1 1 

1 l^^iii 

1 1 

J 

\ \ 

\ • ••.• ; " t 

1 |i! ili i 

1 Iiiiil 

1 Iii; iii iiiii 

1 liii iiiii 

j liiiiii i 

1 1 

|-

1 \ liillii 

1 • • li-iiiii 

1 •liiiiii? 

1 • liiiiiii 

I I 

1 •' • i 

1 • • ii iiiii 

I • ^ .liiiiiiiii 

1- . 1 

i ;• : • il 

1 liiiiiiiii 

1 |:iiiii iii 

1 -i^ ^ 

( g ^ 

1 9 

5. Piping - Material (Check (V) all that apply) 

Bare Steel 

Bare Steel Wrapped 

Galvanized Steel 

Fiberglass Reinforced Plastic 

Copper 

CathodicaUy Protected 

Double Walled 

Secondary containment 

Unknown 

Not in Contact With Soil 

Other Material, Please Specify 

6. Piping - Type (Check (V) all that apply 

Suction - no valve at tank 

Suction - valve at tank 

Pressure 

Gravity Feed 

Has Piping been Repaired? 

Check (V) box if Yes 

Date of Repair 

1 1 

iiiil |o t 

1 1 

iiiil . -.jlii i 

. 1 - 1 

BSKij . •• \m m 

\ 1 

iiiiil • liiiiiiiii 

1 1 

iiiiiiiiil \s m 

1 • 1 

1 liiiiiiiiiN 

1 • • liiiiii 

L • liiiiiii 

:;;i:i:;ii:iilii: , j-;|:;i|::;:-

1 iiiiiiiii'iii 

iiiii iiiil |:;a::|i; 

liiMiii; 

Iiiiiiiiil J 

iii iiiiiiiiil _ | 

' 

I I 

iWiil .:.:•:! 

1 1 

•ii| - -I 

1 1 

I I 

iiiiil :• i 

1 1 

iiiiiiliiiij • : , 'I 

liiiliiiiliiiil •• - 1 

1 1 

1 1 

1 1 

1 1 

1 1 

I I 

1 

iiiiiiiiil • . • 1 

1 1 

iiiiiiiiiil - 1 

1 : 1 

ii: i;-: ^.- • • vi i 

1 1 

iiiiil . : 1 

1 1 

iiiiil , 1 

1 1/ / _ ^ ^-J t 

January 2008 Page 10 of 11 DEQ-05-LQ-016A 
i NOTIFICATION AND DESCRIPTION OF UNDERGROUND STORAGE TANK SYSTEMS 

(Complete for each tank at this location) 

Tank Identification Number 

Tank No. Tank No. Tank No. Tank No. Tank No. 

7. Substance Currently or Last Stored in Greatest Quantity by Volume 

(Check (V) Only One Substance Per Tank) 

Gasoline [ [ 

Diesel ] 

Gasohol 

Kerosene 

Heating Oil 

Used Oil 

Hazardous Substance 

CERCLA Name and/or 

CAS Number 

Mixture of Substances 

Please Specify Mixture 

Other 

Please Specify Other 

8. Release Detection (Check (V) all that Apply 

Manual Tank Gauging 

Tank Tightness;Testingi 

Inventory Control 

Automatic TahkiiGiEigihgli 

Vapor Monitoring 

Groundwater Monitoring 

Secondary Containment [ 

Automatic Line Leak Detector 

Line tightness Testing 

No Release Detection Required 

(Emergency Generator // Field Constructed Tanks) 

Other Method Allowed by 

Department 

Other Method, Please Specify 

9. Spill and Overfill Protection 

Overfill Device Installed 

Spill Device Installed 

January 2008 Page 11 of 11 DEQ-05-LQ-016A 

^^o^ 

DEQ 

State of Oregon 

Department of 

Environmental 

Quality 

CERTIFICATE TO OPERATE 

UNDERGROUND, STORAGE TANKS 

REGISTRATION CERTIFICATE NUMBER: 

24-7752-2008:-OPER. 

FACILITY NAME AND LOCATION 

SALEM MOTOR POOL , • 

1100 AIRPORT RD SE ' , -/1' , ;: 

SALEM, OR 97301-6082 

TANK PERMIT 

BCHHJ 

BCHJK 

BCHJA 

BCHJB 

TANK ID NO 

lA 

3A 

4A 

5A 

TANK SIZE 

20,000 Gallons 

^20,000 Gallons 

1,000 Gallons 

600 Gallons 

PERMITTEE 

Richard Maxwell 

Oregon Dept of Administrative Services 

1100 Airport RdSE 

Salem, OR 97301-6082 

TANK CONTENTS 

Gasoline 

Diesel 

MOTOR OIL 

Used Oil 

CERTIFICATE EXPIRES: June 30, 2009 

ISSUE DATE: 06/05/2008 (3Uvx<feif^^ 

Andree Pollock, UST Program Manager 

Land Quality Division 

Post this certificate where it is visible to the person delivering fuel. 
- ^ ^ 

^ 

Slate of Oregon 

The Oregon Department ofEnvironmental Quality issues this 

annual operating certificate with the understanding that the permittee will 

operate in accordance with the conditions and requirements ofthe general 

De^^rtm^ permit to operate an underground storage tank (UST) pursuant to OAR 

E^on^n., 340.150-0163. 

Posting of the annual operating certificate: 

The permittee must post the annual operating certificate in a conspicuous location at the UST facility 

clearly visible to those depositing regulated substances into the UST. The permittee shall, upon request, 

present it to a Department of Environmental Quality representative. The operating certificate is weatherresistant. 

The annual operating certificate will automatically terminate: 

• 60 days after a change in ownership ofthe property, a change in tank ownership or a change in 

the designated permittee; 

• Upon issuance of a temporary closure certificate or when temporary closure, change-in-service or 

permanent closure begins; 

• On the expiration date. 

To report changes in designated permittee, tank ownership, property ownership or uses ofthe tank 

or to obtain copies of the Oregon laws and rules that apply to the operation of USTs: 

• Call 503-229-6652 or leave a message at 1-800-742-7878 (toll-free in Oregon) 

• Fax to 503-229-6977 

• E-mail to tanks.info@deq.state.or.us 

• Mail to: Oregon Department of Environmental Quality 

Underground Storage Tank Program 

811 SW 6th Avenue 

Portland, OR 97204 

• For copies of laws, rules or forms go to the UST Program Web site at: 

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

Suspected and actual releases from USTs must be reported to DEQ within 24 hours by contacting: 

• Northwest Region - Portland Office (Clackamas, Clatsop, Columbia, Multnomah, Tillamook and 

Washington) http://www.deq.state.or.us/nwr/offices.htm 

• Western Region - Salem Office (Benton, Lane, Lincoln, Linn, Marion, Polk and Yamhill) 

http://www.deq.state.or.us/wr/ol'fices.htm 

• Western Region - Coos Bay Office (Coos, Curry, Douglas, Jackson and Josephine) 

http://www.deq.state.or.us/wr/offices.htm 

• Eastern Region (Baker, Crook, Deschutes, Gilliam, Grant, Harney, Hood River, Jefferson, 

Klamath, Lake, Malheur, Morrow, Sherman, Umatilla, Union, Wallowa, Wasco and Wheeler) 

http://www.deq.state.or.us/er/olTices.htm 

• Oregon Emergency Management Division's Oregon Emergency Response System (OERS) at 1-

800-452-0311 if a DEQ Regional Office cannot be reached and an emergency condition existsbe specific that it involves a spill or release from underground storage tanks. 

!• • 

f \ YOUR TANK 

' liJIV. TODAY ? 

»*»»(» 

DEQ 

State of Otegon 

Depdrtment of 

Environmental 

Quality 

OREGON DEPARTMENT OF ENVIRONMENTAL QUALITY 

UNDERGROUND STORAGE TANK PROGRAM 

GENERAL PERMIT REGISTRATION FORM 

t o DECOMMISSION EXISTING UNREGISTERED TANKS 

and 

30-DAY NOTICE OF INTENT TO DECOMMISSION USTS 

This form for registration of existing tanks that have never been reported to DEQ 

should be submitted at least 30-days before beginning decommissioning by 

permanent closure. 

To register existing tanks you must submit pages 4 through 8 of this registration form 

and a check for the amount ofthe required registration fee. See page 4 to calculate 

the required fee. ^ . 

If you are registering more than five (5) tanks, please make a copy of pages 7 and 8. 

List the additional tanks on the copy. 

You must call your regional office to receive authorization to proceed with the 

decommissioning at least 72 hours prior to begirming work. See page 3 for phone 

numbers. 

You must submit the Underground Storage Tank Decommissioning Checklist and 

Site Assessment Report to your local Regional Office within 30 days following 

completion ofthe tank decommissioning or change-in-service regardless if cleanup 

work is ongoing. 

CHECKLIST 

1. Be sure signatures are provided for the tank owner, permittee and property 

owner, even where one person fills all three roles. 

2. Complete the registration form for all tanks being registered at the facility. 

3. Make copies for your records. 

4. Enclose your check payable to: 

Oregon Department ofEnvironmental Quality 

5. Please retttm the general permit registration form and applicable 

registration fee to: 

Department ofEnvironmental Quality 

Business Office 

811 SW Sixth Avenue 

Portland, Oregon 97204 

October 2008 Page 1 of 8 08-LQ-099 
INSTRUCTION PAGE 

DESCRIPTION OF GENERAL PERMIT PROGRAM 

In lieu of issuing individual permits, Oregon's UST permitting program has adopted a general permit by 

rule to decommission USTs that identifies the conditions and requirements for temporary and permanent. 

closure or completing a change-in-service. By signing the registration forms, you are certifying that you 

will comply with all the conditions and requirements ofthe general permit to decommission USTs. 

DEFINITIONS 

Facility - the place where the tank is located. 

Decommission - means temporary or permanent closure, including temporary or permaiient removal from 

operation, filling in-place, removal from the ground or change-in-service to non-regulated status. 

Owner - means a person who currently owns an UST or owned an UST during the tanks operational life. If 

registered with the Secretary of State, Corporations Division, the UST owner is the legal business name. 

Permittee - means the owner or person designated by the owner, who is in control or has responsibility for 

daily UST system operation and maintenance, financial responsibility and UST operator training 

requirements under a general permit pursuant to OAR 340-150-0160 through 340-150-0168. If registered 

with the Secretary of State, Corporations Division, the permittee is the legal business name. The permittee 

is mailed the aimual compliance fee invoice. 

Property owner - means the legal owner ofthe real property on which an UST is located (the name that 

appears on the County deed records). 

GENERAL PERMIT REGISTRATION FORM 

1. Please fill in the name, address and phone number ofthe facility. If this facility is registered with DEQ 

please include the DEQ facility number. 

2. Please fill in the number of tanks in the space provided in the general permit registration fee section. 

For existing tanks not previously registered, back fees are required by OAR 340-150-0110 (6). 

Calculate the total amount due. 

3. Please fill in the tank owner's legal name, address and phone number. The legal name is the name of 

the tank owner as filed with the Secretary of State, Corporations Division, if applicable. The tank 

owner must sign the regisfration form. 

4. The tank owner can designate a permittee for each facility. Please ask the permittee in charge ofthe 

facility to fill in their legal name, address and phone number. The legal name is the name ofthe 

permittee as filed with the Secretary of State, Corporations Division, if applicable. The permittee must 

sign the registration form. 

5. Please fill in the property owner's name, address and phone number. The property owner's name 

should be the name in the county deed records. The property owner must sign the regisfration form. 

6. There must be three signatures for each completed regisfration form - the tarik owner, permittee and 

property owner. IF ONE PERSON FILLS ALL THREE ROLES, THAT PERSON MUST SIGN 

THREETIMES. 

7. Complete all sections and pages ofthe form. 

LICENSED SERVICE PROVIDERS AND SUPJERVISORS 

ORS 466.750 and OAR 340 - Division 160 requires that licensed service providers perform tank 

decommission work. If contaminated soil is discovered during decommissioning, and a decision is made to 

remediate the site using the soil mafrix rules, ORS 466.750 and OAR 340 - Division 162 requires that 

licensed service providers perform soil matrix cleanup work. During certain critical phases as specified in 

the rules, a licensed supervisor must be present on site to monitor the work. A list of Hcensed service 

providers and supervisors is available upon request by calling (503) 229-6652 or toll-free in Oregon 1-800-

742-7878 (a message answering machine). NOTE: AN OWNER OR PERMITTEE MAY PERFORM 

UST SERVICES ONLY IF THEY HAVE TAKEN AND PASSED THE APPROPRIATE UST 

SUPERVISOR EXAMINATION OFFERED BY A NATIONAL TESTING SERVICE (OAR 340-

150-0156). 

October 2008 Page 2 of 8 08-LQ-099 
INSTRUCTION PAGE 

HELP WITH Tin s REGISTRATION FORM 

If you have any questions about this regisfration form, please phone the DEQ UST Program at (503) 229-

6652. You can also phone the UST Program's toll-free Oregon number, 1-800-742-7878. This is a 

message answering machine for calls made in Oregon. Underground Storage Tank Program staff will 

retum your call within 24hours (one business day). You can also send an e-mail to 

tanks.info@deq.state.or.us. Our regional staff is also available to answer questions regarding the 

general permit program and this general permit regisfration form (see below for telephone numbers). 

COPIES OF GENERAL PERMIT CONDITIONS AND REQUIREMENTS AND 

UST PROGRAM RULES 

• \ • ' • • . 

Copies ofthe general permit to decommission conditions and requirements and UST Program rules and 

laws can be obtained from: 

f ' • .' • 

1. Any of the DEQ offices Hsted below, 

2. By calling the UST HELPLINE at 1-800-742-7878, 

3. Send an e-mail to tanks.info@deq.state.or.us. or 

4. Dovvnloading from the UST home page at: 

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

View Oregon Adminisfrative Rules (OAR) and open Division 150 to OAR 34-150-0166 & 340-150-0168. 

View Oregon Revised Statutes (ORS) and open Chapter 466 to ORS 466.706 to 466.845 

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 

Phone: 541-298-7255 

NORTHWEST REGION 

Phone: 503-229-5263 

UST HELPLINE: 1-800-742-7878 

(toll free in Oregon) 

WESTERN REGION / SALEM 

Phone:503-378-8240 

WESTERN REGION / COOS BAY 

Phone: 541-269-2721 

WESTERN REGION / EUGENE 

Phone:541-686-7838 

October 2008 Page 3 of 8 08-LQ-099 
GENERAL PERMIT REGISTRATION FORM 

TO DECOMMISSION UNREGISTERED USTs 

IMLFSA^If, IHMKff 

FACILITY NAME: 

FACILITY ADDRESS: 

CITY, STATE & ZIP: 

PHONE: ^ FACILITY NUMBER: ^___^^ ^ 

(If known) 

GENERAL PERMIT REGISTRATION FEE 

For existing tanks installed in 1988 or earlier the registration fee is $500 per tank. 

Number of existing tanks being registered __ ^ x $500 = $ Total Fee Due 

Note: If an existing tank was installed after 1988 please contact the Department at 503-

229-6652 or 1 -800-742-7878 for assistance in calculating the fee. 

For existing tanks not previously registered and permitted, back fees are due and payable 

with this general permit registration form in accordance with OAR 340-150-0110 (6). 

30-DAY NOTICE OF INTENT TO DECOMMISSION INFORMATION 

Wor k T o B e Performe d By : ''-- •-.- '•• •''-• - ' ' ' ' ' ' • ' ' .. . 

(Name of Permittee, Tank Owner, Property Owner or Licensed Service Provider) 

If performed by Service Provider: License # ' • ••••':••' • •'-•• 

Contact Phone: Contact Mobile Phone: i 

Will tank removal or potential cleanup affect adjacent property or right-of-way property? 

Yes No 

Date decommissioning is scheduled to begin: 

October 2008 , Page 4 of 8 08-LQ-099 
y 

GENERAL PERMIT REGISTRATION FORM 

TO DECOMMISSION UNREGISTERED USTs 

1. TAN K OWNER'* ^ as registered with 

the Secretary of State, Corporations-Division 

Name of Official (Please Print) 

Signature of Official , Date 

Mailing Address (Please Print) 

City, State and Zip Code 

Area Code and Telephone Nimiber 

I will decommission the USTs described on the Notification and Description of Underground Storage Tank 

Systems pages in accordance with the conditions and requirements ofthe general permit to decommission. 

2 . PERMITTEE * as registered with the 

Secretary of State, Corporations Division 

Name of Official (Please Print) 

Signature of Official Date 

. • • ' •: . • / ^- ^ : : : •• • ' . ' • • • ' 

Mailing Address (Please Print) 

City, State and Zip Code 

Area Code and Telephone Number 

I will decommission the USTs described on the Notification and Description of Underground Storage Tank 

Systems pages in accordance with the conditions and requirements ofthe general permit to decommission. 

3 . PROPERT Y OWNE R is name that 

appears on the County deed record for this property. 

Name of Official (Please Print) 

Signature of Official Date 

Mailing Address (Please Print) 

City, State and Zip Code 

Area Code and Telephone Number ' 

* If this facility or tanks are owned by a person, or operated by a permittee that is a business registered with the 

Secretary of State, Corporations Division, you must use that legal business name for purposes of registering these USTs 

with the Department. Please make sure that your business registration with the Oregon Corporations Division (503-

986-2200) is active or your application may be placed on hold until your registration has been renewed. 

Return Completed Form to: Department ofEnvironmental Quality 

Business Office 

8tl SW Sixth Avenue 

Portland, OR 97204 . 

October 2008 Page 5 of 8 08-LQ-099 
"\. 

Notification and Description of Underground Storage Tanic Systems 

TYPE OF OWNER INDIAN COUNTRY 

Federal Government | j Commercial 

State Govemment | | Private 

[ J Local Government 

a 

Tanks are located on land within an Indian 

Reservation or on trust lands outside 

reservation boundaries. 

Tanks are owned by a Native American 

nation or tribe. 

• 

Tribe or Nation: 

TYPE OF FACILITY 

[ J Gas Station 

I . I Petroleum Distributor 

I I Air Taxi (Airiine) 

I [Aircraft Owner 

I [Auto Dealership 

Railroad 

Federal - Non-Military 

Federal - Military 

Industrial 

Contractor 

Trucking/Transport 

Utilities 

Residential 

Farm 

Other (Explain) .: 

FINANCIAL RESPONSIBILITY 

I 11-will meet the financial responsibility requirements 

in accordance with OAR 340 - Division 151 

Check All that Apply 

I J Pollution Liability Insurance 

[ I Self Insurance 

I I Exempt (Federal or State Government 

I I Letter of Credit 

[ J Surety Bond 

I I Guarantee 

1 I Local Govemment 

The financial responsibility requirements are designed to make sure that the tank owner, property owner or 

permittee can pay the costs of cleaning up leaks and compensating third parties for bodily injury and 

property damage caused by leaking USTs. A plain language summary ofthe financial responsibility 

requirements can be downloaded from the Internet at http://www.epa.gov/swerust1/pubs/dollars.htm. For a 

list of known insurance providers go to http://www.epa.gov/swerust1/pubs/inslist.htm. 

CONTACT PERSON IN CHARGE OF TANKS 

Name; Job Title: Address: Phone Number (Include Area Code): 

CERTIFICATION (Read and sign after completing all section) 

I certify under penalty of law that I have personally examined and am familiar with the information submitted in this and all attached documents, and that based 

on my inquiry of those individuals Immediately responsible for obtaining the information, I believe that the submitted infonnation is true, accurate, and complete. 

Name and official title of owner or owner's 

authorized representative (Print) 

Title: ::mMZ^mz^-zmmmMm 

Signature Date Signed 

October 2008 Page 6 of 8 08-LQ-099 
NOTIFICATION AND DESCRIPTION OF UNDERGROUND STORAGE TANK SYSTEMS 

^ ^ (Complete for each tank at this location) 

^ R k Identification Number Tank No. Tan k No . Tan k No . Tan k No . Tank No. 

1. Status of Tank (Check (V) only one) 

Currently in Use 

Temporarily Out of Use 

Permanently Out of Use 

2. Date of Installation (month & year) 

3. Estimated Total Capacity (gallons) 

1 1 

1 ll 

1 1 

il 

1 :: 1 

L 1 

1 1 

1 1 

1 . 1 

1 -- 1 

1 • 1 

1 1 

1 1 

4. Material of Construction (Check (V) all that apply) 

Asphalt Coated or Bare Steel 

CathodicaUy Protected Steel 

Epoxy Coated Steel 

Composite (Steel with Fiberglass) 

Fiberglass Reinforced Plastic 

Lined Interior 

Double Walled 

Polyethylene Tank Jacket 

Concrete 

Excavation Liner 

Unknown 

^ ^ Other Material, PleiseiSfecify 

^ ^ Has Tank been Repaired? 

Check rV) Box if Yes 

Date of Repairs 

' 

1 1 

1 : 1 

1 1 

1 1 

1 1 

1 1 

1 1 

1 1 

1 1 

il 1 

1 1 

; . •. • ? 

1 1 

. • • • • 

1 1 

1 1 

1 1 

1 1 

I . I 

1 1 

1 1 

1 1 

1 1 

1 1 

1 1 

5. Piping - Material (Check (V) ail that apply 

Bare Steel 

Bare Steel Wrapped 

Galvanized Steel 

Fiberglass Reinforced Plastic 

Copper 

. CathodicaUy Protected 

Double Walled 

Secondary Containment 

Unknown 

Not in Contact with Sdill 

Other Material, Please Specify 

1 

1 

1 

:l . li 

1 1 

1 1 

1 1 

1 1 

1 1 

1 1 

1 1 

1 1 

I I 

1 1 

1 1 

1 1 

1 1 

1 1 

1 1 

1 1 

1 1 

6. Piping - Type (Check (V) all that apply) 

Suction - No Valve at Tank 

Suction - Valve at Tank 

Pressure 

Gravity Feed 

Has Piping been Repaired? 

9 Check N) Box if Yes 

Date of Repair 

1- • ^^ ^ 1 

1 1 

1 1 

1 1 

1 

1 , - ^^•— 1 

I---'- - 1 

1—• • 1 

1^ -• --- 1 

1 ---.•— 1 

l-v. ^ --- 1 

1. '^^ --- 1 

l-i-:-:--^- : 1 

1 

I--— — 1 

1 ^ — ••: 1 

\ \ 

[ -^iiii-^ - 1 

1 

I:-.-:.:' - 1 

1 H 

1-—-1 

h--^---i-: | 

1 

October 2008 Page 7 of 8 08-LQ-099 
NOTIFICATION AND DESCRIPTION OF UNDERGROUND STORAGE TANK SYSTEMS ^ 

^Complete for each tank at this location) '^ ^ 

Tank Identification Number Tank No. Tank No. Tank No. Tank No. Tank No. 

7. Substance Currently or Last Stored in Greatest Quantity by Vojume 

Check (^l) Ohiv One Substance Der Tank) 

Gasoline 

Diesel 

Gasohol 

Kerosene 

Heating Oil 

Used Oil 

1 1 

1 1 

1 1 

1 1 

1 1 

1 \ 

1 1 

1 r 

1 1 

\ 1 

1 1 

i i 

« ! • 1: 

Hazardous Substance 

CERCLA NarmSaMbB 

CAS Number 

1 1 1 1 

• : .- . • :.^ - "• • • 

1 1 I I 1 1 

1 •. . . ' . ' 

Mixture of Substances 

Please Specify Mixture 

1 i 1 1 1 1 1 1 1 1 

^ 

Other 

Please Specify Other 

1 1 1 1 1 1 

• ,. ' 

1 1 1 - ^ 

8. Release Detection (Check (V) all that Apply 

Manual Tank Gauging 

Tank Tightness Testing 

Inventory Control 

Automatic Tank Gauging 

Vapor Monitoring 

Groundwater Monitoring 

Secondary Containment 

Automatic Line Leak Detector 

Line Tightness Testing 

No Release Detection Required 

(Emergency Generator // 

Field Constructed Tanks) 

Other Method Allowed by Depalment 

Other Method, Please Specify 

Tank 

1 1 

1 1 

1 1 

1 1 

1 1 

1 Is 

1 1 B 

1 1 

1 1 

Pipe 1 Tank | Pipe | Tank | Pipe | Tank | Pipe | Tank | Pipe 

m 1 1 

1 1 

1 1 

1 1 

1 ll 

1 1 

1 1 

1 1 

1 1 

1 1^ 

1 1 

1 li 

1 1 

1 If 

1 1 • • 

^^1 

1 1 

1 1 

• 

\ \ 

1 1 

fl 1 

1 1 

1 l f 

1 1 

1 1 

1 1 

1 V 

1 1 : 

1 

1 1 

1 i :|i i 

^^H 

^^H ^nm 

1 li 

1 1 

::L_Jl 

1 i 

I If 

1 1 

1 1 

1 1 

1 1 

1 1 

1 1 

1 1 

1 1 

1 1 

1 1 

^ ^ M ^^1 

1 1 

1 1 

• 

1 jf 

1 1 

1 |i 

1 1 

1 1 

1 1 

i i 

1 1 

1 i i 

1 [: 

1 1 

1 1 

^^H 

^^H l^^l 

1 1 

1 1 

1 1 

1 1 

J If 

1 1 

1 1 

i i 

1 

9. Spill and Overfill Protection 

Overfill Device Installed 

Spill Device Installed 

1 1 1 1 

• 1^-----^ ^ - 1 

1 1 

I - - -1 

1 1 

^ ^ 

October 2008 Page 8 of 8 08-LQ-099 

- < ^ f^ 

DEQ 

state of Oregon 

Department of 

Environmental 

Quality 

OREGON DEPARTMENT OF ENVIRONMENTAL QUALITY 

UNDERGROUND STORAGE TANK PROGRAM 

GENERAL PERMIT REGISTRATION FORM 

FOR DEQ USE ONLY 

Date Rec'd 

CkNo. 

Amt Rec'd $ 

UST Pemiit 

. . - ' fc* • • . #• - / . * 

This form is to be used when there is a change of tank owner, permittee or property owner. This 

form must be retumed within 120 days of a change in tank owner, permittee or property owner so 

that a revised General Permit Certificate to Operate can be issued to insure the facility can continue 

to legally receive product deliveries such as motor fiiel. 

A $75 permit modification fee must accompany this form. 

Before DEQ can issue a new General Permit Certificate to Operate, you must submit proof of 

compliance with the financial responsibility rules. Acceptable mechanisms for demonstrating 

compliance with pollution liability requirements are found in OAR Chapter 340 - Division 151 and 

described in the publication Dollars and Sense. To obtain a copy of Dollars and Sense call 503-

229-6652 or download it from the Intemet at http://www.epa.gov/swerustl/pubs/dollars.htm. 

FACILITY NAME: 

FACILITY ADDRESS: 

CITY, STATE & ZIP: 

^ ClF 

DATE OWNER/PERMITTEE INFORMATION CHANGED: 

PHONE: 

SIC CODE: 

FACILITY NUMBER: 

1. 

2. 

3. 

4. 

REMINDER 

Be sure signatures are provided for tank owner, permittee and properly owner, even where one 

person fills all three roles. 

Make copies for your records. 

Include a check or money order for $75 payable to DEQ. 

Please retum the general permit modification form, financial responsibility verification 

documents (i.e. Certificate of Insurance, Letter from Chief Financial Officer, etc.) and fee to: 

DEQ Business Office 

811 SW 6*" Avenue 

Portland, Oregon 97204 

August 2007 Page 1 of3 DEQ-0S-LQ-018A 
INSTRUCTION PAGE 

UST SYSTEM OPERATOR REQUIRED 

The owner or permittee ofeaeh UST facility issued an operating certificate that dispenses a regulated substance from an 

UST to a motor vehicle or container must employ trained personnel who can properly operate and mamtain the UST 

system and provide emergency response information to any person that dispenses a regulated substance from the UST 

system. For more details on unplementing this requirement see rule OAR 340-150-0200 or go to 

http://www.deq.state.or.us/lq/training.htm#Train ing. . -

HELP WITH THIS PERMIT MODIFICATION FORM 

If you have any questions about this permit modification form, please phone the DEQ UST Program at (503) 229-6652. You 

can also phone the UST Program's toll-free number, 1-800-742-7878. This is a message answering machine for calls made 

within Oregon. Underground Storage Tank Program staff will retum your calls within 24 hours. You can also send an email to tanks.info@deq.state.or.us. Our regional staff are also available to answer questions regarding the general permit ^ 

program and this permit modification form (see below for telephone numbers). 

COPIES OF GENERAL PERMIT CONDITIONS AND REQUIREMENTS AND 

UST PROGRAM RULES , 

Copies ofthe general permit to operate conditions and requirements and UST Program rules and laws can be obtained from: 

1. Any of the DEQ offices listed below, 

2. By calling the UST HELPLINE at 1-800-742-7878, 

3. tanks.info(5),deq.state.or.us, or 

4. Downloading from the UST home page at: 

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

NORTHWEST REGION 

Clackamas, Clatsop, 

Columbia, Multnomah, 

Tillamook & Washington 

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, 

Mon'ow, 

Shemnan, 

Umatilla, Union, 

Wasco, Wheeler 

& Wallowa 

Counties 

EASTERN REGION/THE DALLES 

Phone:(541)298-7255 

NORTHWEST REGION 

Phone:(503)229-5263 

UST HELPLINE (IN OREGON) 

1-800-742-7878 

WESTERN REGION / COOS BAY 

Phone: (541) 269-2721, Ext. 31 

WESTERN REGION / EUGENE 

Phone: (541) 686-7838 

WESTERN REGION / SALEM 

Phone: (503) 378-8240 

V , ' 

August 2007 Page 2 of3 DEQ-05-LQ-018A 
TO MODIFY OWNERSHIP OR PERMITTEE INFORMATION 

GENERAL PERMIT REGISTRATION FORM 

TO OPERATE USTs 

1. TAN K OWNER * as registered with the 

Secretary of State, Corporations Division 

Name of Official (Please Print) 

Signature of Official Date 

Mailing Address (Please Print) 

City, State and Zip Code 

••.•••'../ ' 

Area Code and Telephone Number 

I will operate the previously registered USTs m accordance with the conditions and requirements ofthe general permit 

pursuant to OAR 340-150-0163. 

2 . PERMITTEE * as registered with the Secretary 

of State, Corporations Division 

Name of Official (Please Print) 

Signature of Official Date 

^1 

Mailing Address (Please Print) 

City, State and Zip Code 

Area Code and Telephone Number 

I will operate the previously registered USTs in accordance with the conditions and requirements ofthe general permit 

pursuant to OAR 340-150-0163. 

3 . PROPERT Y OWNE R is name that appears 

on the County deed record fpr this property. 

Name of Official (Please Print) 

Signature of Official Date 

Mailing Address (Please Print) 

City, State and Zip Code 

Area Code and Telephone Number 

* If this facility or tanks are owned by a person, or operated by a permittee, that is a business registered with the Secretary of State, 

Corporations Division, please use that legal business name for purposes of registering these USTs with the Department. 

If you have any questions, please contact the DEQ UST Program at: 

1-800-742-7878 (toll-free in Oregon) or 1-503-229-6652 (out-of-state) 

Fax Number 503-229-6977 

August 2007 Page 3 of3 DEQ-05-LQ-018A 

^ ^ ^ 

^ 

DEQ 

State of Orsgon 

Department of 

Enviion mental 

Quality 

OREGON DEPARTMENT OF ENVIRONMENTAL QUALITY 

UNDERGROUND STORAGE TANK PROGRAM 

GENERAL PERMIT REGISTRATION FORM 

RETURN TO SERVICE APPLICATION 

u--r-.T'TiL^'"^'•li'"''vr!'^""' ••iT'"'"~T'"r\' ix'^^ir^:\'''^c^^vi- h %'^\'~^t^'• '\.n^ . 

Use this form to obtain an operating certificate for an UST now in temporary closure or whose. 

previous operating certificate was suspended or revoked. This form must be submitted so that a 

General Permit Certificate to Operate can be re-issued to insure the facihty can legally receive 

product deliveries such as motor fiiel. 

Before DEQ can issue a General Permit Certificate to Operate, you must submit proof of 

compliance with the financial responsibility rules. Acceptable mechanisms for demonstrating 

compliance with pollution liability requirements are found in OAR Chapter 340 - Division 151 and 

described in the publication Dollars and Sense. To obtain a copy oi Dollars and Sense call 503-

229-6652 or download it from the Intemet at http://v^rvvw.epa.gov/swerustl/pubs/dollars.htm. 

Upon receipt of an application, UST Inspectors will be notified and given a chance to evaluate the 

operating conditions ofthe USTs. When the facility is deemed in^compliance technically and 

administratively, an operating certificate that allows fuel deliveries will be issued. 

FACILITY NAME: 

FACILITY ADDRESS: 

CITY, STATE & ZIP: 

FACILITY CONTACT NAME: 

FACILITY PHONE: 

FACILITY NUMBER: 

2. 

3. 

REMINDERS 

Be sure signatures are provided for tank owner, permittee and property owner, even where one 

person fills all three roles. 

Make copies for your records. 

If any annual compliance fees are due, any civil penalties have not been paid, or there has been a 

change in permittee, tank owner or property owner, please contact DEQ at 503-229-6652 for 

further instructions. An annual operating certificate will not be issued until all fees are paid. 

Please retum this application form and proof of financial responsibility (i.e. Certificate of 

Insurance, Letter from Chief Financial Officer, etc.) to: 

DEQ 

Tank Program 

811 SW 6* Avenue 

Portland, Oregon 97204 

J 

October 2008 Page 1 of 4 08-LQ-106 
REGULATED SUBSTANCE INFORMATION TO RETURN TO SERVICE 

HELP WITH BRINGING THE UST SYSTEM BACK IN OPERATION 

DEQ, recommends that you retum a previously closed UST system to service with the assistance of a licensed UST Service Provider. 

Electronic equipment may need calibration and seals may dry out in UST systems that have been inactive for a year or more. By 

employing the services of an UST Service Provider, operational problems can be avoided or corrected quickly before more serious 

problems develop, including preventing significant spills or releases from faulty seals or improperly operating leak detection equipment. 

\ 

UST SYSTEM OPERATOR REQUIRED 

The owner or permittee ofeaeh UST facility issued an operating certificate that dispenses a regulated substance from an 

UST to a motor vehicle or container must employ trained personnel who can properly operate and maintain the UST 

system and provide emergency response information to any person that dispenses a regulated substance from the UST 

system. For more details on implementing this requirement see rule OAR 340-150-0200 or go to 

http://vyww.deq.state.or .us/lq/training.htm#Training. 

HELP WITH THIS FORM 

If you have any questions about this retum to service application form, please phone the DEQ UST Program at (503) 229-

6652. You can also phone the UST Program's toll-free number, 1-800-742-7878. This is a message answering machine for 

calls made within Oregbn. Underground Storage Tank Program staff will retum your calls within 24 hours. You can also 

send an e-mail to tanks.info(a),deq.state.or.us. Our regional staff can also answer questions regarding the general permit 

program and this retum to service application form (see below for telephone numbers). 

COPIES OF GENERAL PERMIT CONDITIONS AND REQUIREMENTS AND 

UST PROGRAM RULES CAN BE OBTAEVED FROM: 

1. Any ofthe DEQ offices listed below, 

2. By calling the UST HELPLINE at 1-800-742-7878, 

3. tanks.info@,deq.state.or.us, or 

4. Downloading from the UST home page at: 

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

NORTHWEST REGION: 

Clackamas, Clatsop, 

Columbia, Multnomah, 

Tillamook & Washington 

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 

Phone:(541)298-7255 

NORTHWEST REGION 

Phone: (503) 229-5263 

UST HELPLINE (IN OREGON 

lc800-742-7878 

WESTERN REGION / COOS BAY 

Phone: (541) 269-2721, Ext. 31 

WESTERN REGION / EUGENE 

Phone: (541) 686-7838 

WESTERN REGION / SALEM 

Phone: (503) 378-8240 

October 2008 -Page 2 of 4 08-LQ-106 
REGULATED SUBSTANCE INFORMATION TO RETURN TO SERVICE 

GENERAL PERMIT REGISTRATION FORM 

TO OPERATE USTs 

1. TAN K OWNER * as registered with the 

Secretary of State, Corporations Division 

Name of Official (PteasePn/i^ 

Signature of Official Date 

Mailing Address (Please Print) 

City, State and Zip Code 

Area Code and Telephone Number 

I will operate the previously registered USTs in accordance with the conditions and requirements ofthe general permit 

pursuant to OAR 340-150-0163. 

2 . PERMITTEE * as registered with the Secretary 

of State, Corporations Division 

Name of Official (Please Print) 

Signature of Official Date 

Mailing Address (Please Print) 

City, State and Zip Code 

Area Code and Telephone Number 

I will operate the previously registered USTs in accordance with the conditions and requirements ofthe general permit 

pursuant to OAR 340-150-0163. 

3 . PROPERT Y OWNE R is name that appears 

on the County deed record for this property. 

'Name of Official (Please Print) 

Signature of Official Date 

• ' • ' ••/• : , • • . • • . • . : .-J -

Mailing Address (Please Print) 

City, State and Zip Code 

Area Code and Telephone Number 

* If this facility or tanks are owned by a person, or operated by a permittee, that is a business registered with the Secretary of State, 

Corporations Division, please use that legal business name for purposes of registering these USTs with the Department. 

If you have any questions, please contact the DEQ UST Program at: 

1 -800-742-7878 (toll-free In Oregon) or 1 -503-229-6652 (out-of-state) 

Fax Number 503-229-6977 

October 2008 Page 3 of 4 08-LQ-106 
REGULATED SUBSTANCE INFORMATION TO RETURN TO SERVICE 

For the purposes of filling in the table below, any motor fuel containing up to 10% ethanol shall be 

considered gasoline and reported on the "gasoline" line. Any gasoline containing more than 10% 

ethanol shall be considered an "other" fuel and reported on the "other" line. On the "please specify 

other" line please indicate the ethanol content ofthe fiiel such as 85% or E85. 

For the purposes of filling in the table below, any motor fuel containing any quantity of biodiesel (i. e. 

10% or BIO, 20% or B20, 99% or B99) shall be considered an "other" fuel and reported on the "other" 

line. On the "please specify other" line please indicate the biodiesel content ofthe fuel such as 20% or 

B20. If you are dispensing an altemate fuel that is 100%) or B100, that is not considered a regulated 

substance at this time and the UST does not require a DEQ operating certificate at this time. 

Finally, "gasohol" is an antiquated term and DEQ would not expect tank owners to use this line. 

However, this term remains on the federal reporting form so DEQ has lefl it on the state form until such 

time as the Environmental Protection Agency updates the national reporting program. 

NOTIFICATION AND DESCRIPTION OF UNDERGROUND STORAGE TANK SYSTEMS 

(Complete for each tank at this location) 

Tank Identification Number 

Tank No. Tank No. Tank No. Tank No. Tank No. 

7. Substance Currently or Last Stored in Greatest Quantity by Volume 

(Check (V) Only One Substance Per Tank) 

Gasoline 

Diesel 

Gasohol 

Kerosene 

Heating Oil 

Used Oil 

Hazardous Substance 

;r K 

CAS Number 

|;:; | - • • 1.; ; 

: 1 1 

1 1^^ 

1 - 1 

1 1 

1 1 

? l • . . j : 

1 1 

1 1 

1 : : 1 1 1 

il ". ; i 

1 1 

\ - ;: •• ,;• ";• • :f i 

1 1 

:-••/ : • •• •• •:: i 

1 1 

Mixture of Substances 

Please Specify Mixture 

1 1 1 1 1 1 1 1 1 1 

Other 

Please Specify Other 

1 : 1 I I 1 : :: . ::| |.,.::•::.:. . .,.., | 1- -^---1 

October 2008 Page 4 of 4 08-LQ-106