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

## OREGO N DEPARTMEN TO F ENVIRONMENTA L QUALIT Y UNDERGROUN D STORAG E TAN KPROGRA M GENERA L PERMI TREGISTRATIO N FOR M

AN D 30-DA YNOTIC E

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### Complet e on e genera l permi t registratio n packag e fo reac h separat e facilit yyo u ar e registering . Eac h registratio n packag e Include s th e registratio n for m (page s 7 & 8 ) wit h signatur e blocks , a fe e matri xt o calculat e th e require d registratio n fe e (pag e 7 ) an d th e notificatio n an d descriptio n o f undergroun d storag e tan k system s (page s 9 , 1 0 & 11) . I f yo u ar e installin g mor e tha n fiv e (5 ) tanks , pleas e mak e additiona l copie s o f th e descriptio n page s (page s 9 , 1 0 & 11 ) an d lis t th e additiona l tank s o n th e copie s yo u make . Yo u mus t cal l you rregiona l offic e t o receiv e authorizatio n t o procee d wit h th e installatio n 7 2 hour s prio rt o beginnin g work . Se e pag e 4 fo roffic e locations . CHECKLIS T ^ B e sur e signature s ar e provide dfor th e tan k owner , permitte e an dproperty owner , eve n wher e on e perso n fills al l thre e roles . ^ Complet e th e registratio n form(page s 7 an d8 ) an dth e notificatio n an ddescriptio n o f undergroun dstorag e tan k system s (page s 9 , 1 0 & 11 ) for all tank s bein g installe dat th e facility . ^ Mak e copies for

you r records . v ^ Enclos e you r

chec k payabl e to : Orego n Departmen t

o f Environmenta l Quality ^ Retu mth e genera l permi t registratio n for

m(page s 7 an d8) , th e notificatio n an d descriptio n o f

undergroun dstorag e tan k system s (page s 9 , 10' & 11 ) an dth e correc t tota l fe e amoun t

to : DE Q Busines s Offic e 81 1 S W 6**'Avenu e Portland , Orego n 9720 4

Januar y 200 8 Pag e lo f 1 1 DEQ-05-LQ-016 A

## GENERA LINFORMATIO N PAG E

DESCRIPTIO N O FGENERA LPERMI T PROGRA M I n lie u o f issuin g individua l pennits , Oregon' s US T permittin g programha s adopte dgeneral permit s b y rule'a s follows : Genera l Permi t

t o Instal l (OA R340-150-0160) : thi s rul e identifie s th e condition s an d requirement s tha t

cove r th e constructio n o f

a n US T system . Genera l Permi t

t o Operat e (OA R340-150-0163) : thi s rul e identifie s th e condition s an d requirement s tha t

cover s th e operatio n o f

a n US T syste mthat

meet s th e performanc e standards.fo r

ne w o r upgrade dfacilities . Facilitie s registerin g fo r agenera l permi t

t o operat e ar e authorize dt o deposi t aregulate dsubstanc e suc ha s moto r fuel int o a

n UST . B y signin g th e registratio n forms , yo u ar e certifyin g that yo u wil l compl y withal l th e condition s an drequirement s ofth e genera l permit s t o instal l an doperate . Upo n receip t ofth e complete d registratio n forms , th e Departmen t wil l issu e aRegistratio n Certificat e t o Install . Thi s certificat e doe s no t authoriz e fuel delivery . T o receiv e aCertificat e t o Operat e authorizin g fuel delivery yo u mus t submi t t o you r DE Q regiona l offic e th e followin g documentation : 1 . US T Installatio n Checklist , 2 . Informatio n associate dwithth e equipmen t installe dincludin g alis t

o f majo r syste m components , third-party evaluations , manufacturers ' checklists , photograph s an dfire authority sign-off

, i f available . Whe n yo u receive you r

Certificat e t o Operat e yo u mus t provid e th e Operatin g Certificate Numbe r t o you r fuel distributo r

s o the y can delive r

produc t t o you r facility . 

## DEFINITION S Instal l - mean s th e physica l constructio n o f al l o r part o f a n undergroun dtank , includin g bu t no t limite dto , activitie s suc ha s excavating ; backfilling ; testing ; prope r placemen t

o f tank , piping , releas e detectio n devices ; corrosio n protectio n systems , spil l an doverfil l device s an dan y associate dadministrativ e activitie s suc ha s notifications , recor dkeepin g an drecor dsubmissions . Operat e - mean s depositin g aregulate dsubstanc e into , storin g aregulate dsubstanc e in o r dispensin g aregulate dsubstanc e fro ma n undergroun dstorag e tan k an dsuc hothe r

activities , includin g bu t

no t limite dto , performin g releas e detection , maintainin g corrosio n control , preventin g spill s an doverfills , investigatin g an dconfirmin g suspecte dreleases , conductin g maintenance , modifications , replacemen t an drepair s o f

equipriient , maintainin g financial responsibility an dsubmittin g record s o n th e US T an dundergroun dpiping' s performance . Owne r - mean s aperso n wh o currentl y own s an US T o r owne da n US T durin g th e operationa l lif e ofth e tank . I f

registere dwithth e Secretary o f State , Corporation s Division , th e tan k owne r i s th e legal busines s name . Permitte e - mean s th e owne r o r perso n designate db y th e owner , wh o i s i n contro l o r ha s responsibility for

dail y US T syste moperatio n an dmaintenance , financial responsibility an dUS T operato r trainin g requirement s unde r agenera l permi t

pursuan t t o OA R340-150-016 0 throug h 340-150-0168 . I f

registere dwithth e Secretary o f State , Corporation s Division , th e permitte e i s th e legal busines s name . Th e permitte e i s maile dth e annua l complianc e fe e invoice . Property Owne r

- mean s th e lega l owne r ofth e rea l property o n whic ha n US T i s locate d(th e nam e tha t appear s o n th e County dee drecords) . Registratio n Certificat e - th e documen t th e Departmen t

issue s t o acknowledg e receip t o f a genera l permi t

registratio n form . Th e registratio n certificat e t o operat e authorize s delivery o f regulate dsubstances , includin g moto r fuels . Th e registratio n certificate s t o install , decommissio n o r manag e asyste min temporar y closur e d o no t authoriz e produc t

deliveries . SI C Cod e - Standar dIndustria l Cod e (se e page s 5 & 6 ) Januar y 200 8 ^ Pag e 2 o f 1 1 DEQ-05-LQ-016A

## INSTRUCTIO N PAG E

TANK S REQUIRIN GA GENERA LPERMI T REGISTRATIO N FOR M 1 . Al l undergroun dtanks , mcludin g emergenc y generato r tanks , containin g petroleu mproduct s o r liste d chemicals , whic har e no t

exemp t (example s ar e gasoline , diesel , industria l solvents , pesticide s an d herbicides) . 2 . Tank s an dpipin g with10 % o r mor e o f thei r tota l volum e beneathth e ground . 3 . Farmo r

residentia l moto r

fuel undergroun dtank s large r tha n 1,100 gallon s in capacity . 4 . Tank s containin g regulate dsubstance s an dno t permanentl y decommissione dprio r t o Ma y 1 , 1988 . 

## EXEMP T TANK S (GENERA LPERMI T REGISTRATIO N NO T REQUIRED ) 1 . Farmo r

residentia l moto r

fuel tank s o f

1,100 gallo n capacity o r less . 2 . Heatin g oi l tank s use dfor hea t o n th e sam e propert y wher e th e tank s ar e located . 3 . Septi c Tanks . 4 . Pipelin e Facilities . 5 . Surfac e Impoundments . 6 . StormWate r

o r Wast e Wate r

Collectio n System s 7 . Flow-Throug hProces s Tanks . 8 . Liqui dTraps . 9 . Tank s tha t

are abov e th e surfac e ofth e floo r man undergroun darea . 

## GENERA LPERMI T REGISTRATIO N FOR M 1 . Pleas e fill in th e name , addres s an dphon e numbe r ofth e facility . Includ e th e Facility E ) numbe r if thi s for mi s bein g submitte dfor

an existin g facilit

y tha t ha s previousl y registere dothe r tanks . 2 . Pleas e provid e th e SI C cod e for eac hfacility (Se e page s 5 an d6) . 3 . Fo r ne w tanks , aregistratio n fe e o f $ 135.0 0 pe r

tan k an da n installatio n fee o f

$40 0 pe r tan k ar e du e for th e curren t

year . Fo r

multi-chambere do r

multi-compartmen t

tank , th e registratio n fee i s $135.0 0 an dth e installatio n fe e $40 0 for eac hchambe r

o r compartment . Pleas e fill in th e numbe r o f ne w tank s o r compartment s in th e spac e provide din th e genera l penni t registratio n fee section . Multipl y thi s numbe r b y $53 5 t o calculat e th e tota l amoun t owed . 4 . Pleas e fill in th e tank owner' s lega l name , addres s an dphon e number . Th e legal nam e i s th e nam e o f th e tank owne r a s filedwithth e Secretary o f State , Corporation s Division , if applicable . Th e tan k owne r mus t sig n th e registratio n form . 5 . Th e tank

owne r can nam e apermitte e for eac hfacility . Pleas e as k th e permitte e in charg e ofth e facilit y t o fill in thei r

lega l name , addres s an dphon e number . Th e legal nam e i s th e nam e ofth e permitte e a s filedwithth e Secretary o f State , Corporation s Division , i f applicable . Th e permitte e mus t sig n th e registratio n form . 6 . Pleas e fill in th e propert y owner' s name , addres s an dphon e number . Th e property owner' s nam e shoul db e th e nam e t

n th e county dee drecords . Th e propert y owne r mus t sig n th e registratio n form . 7 . Ther e mus t

b e thre e signature s for

eac hcomplete dregistratio n for m- th e tan k

owner , permitte e an d property owner . I FON EPERSO N FILL S AL LTHRE EROLES , THA T PERSO N MUS T SIG N THRE ETIMES . 8 . Complet e page s 9 , 1 0 an d11 , Notificatio n an dDescriptio n o f Undergroun dStorag e Tan k Systems . 

## LICENSE D SERVIC EPROVIDER S AN D SUPERVISOR S OR S 466.75 0 an dOA RChapte r 340 , Divisio n 16 0 require s tha t license dservic e provider s perfor mtan k installation work . NOTE : A N OWNE RO RPERMITTE EMA Y PERFOR M US T SERVICE S ONL Y I FTHE Y HAV ETAKE N AN D PASSE D TH EAPPROPRL\T EUS T SUPERVISO R EXAMINATIO N OFFERE D B Y A NATIONA LTESTIN GSERVIC E(OA R340-150-0156) . Durin g certai n critica l phase s a s specifie din th e rules , alicense dsuperviso r mus t b e presen t

o n site t o monito r

th e work . List s o f

license dservic e provider s an dsupervisor s are availabl e upo n reques t b y callin g (503 ) 229
- 665 2 o r toll-fi-ee in Orego n 1-800-742-787 8 ( amessag e answerin g machine) . Januar y 200 8 Pag e 3 o f 1 1 DEQ-05-LQ-016 A

## INSTRUCTIO N PAG E

US T SYSTE M OPERATO RREQUIRE D Th e owne r

o r permitte e o f

eac hUS T facility issue dan operatin g certificate tha t dispense s aregulate d substanc e fro ma n US T t o amoto r vehicl e o r

containe r

mus t emplo y traine dpersonne l wh o can properl y operat e an dmaintai n th e US T syste man dprovid e emergenc y respons e mformatio n t o any perso n that dispense s aregulate dsubstanc e fro mth e US T system . Fo r mor e detail s o n implementin g thi s requiremen t

se e rul e OA R340-150-020 0 o r g o t o http://www.deq.state.or.us/lq/training.htm#training . 

## HEL PWIT H THI S REGISTRATIO N FOR M If yo u hav e any question s abou t thi s registratio n form , pleas e phon e th e DE Q US T Progra mat (503 ) 229
- 6652 . Yo u can als o phon e th e US T Program' s toll-fi-ee number , 1-800-742-7878 . Thi s i s amessag e answerin g machin e fo

r call s mad e withi n Oregon . Undergroun dStorag e Tank Programstaf

f wil l retu m you r call s withi n 2 4 hours . Yo u can als o sen dan e-mai l t o tanks.info@.deq.State.or.us . Ou r regiona l staf f ar e als o availabl e t o answe r question s regardin g th e genera l permi t progra man dthi s genera l permi t registratio n for

m(se e belo w for

telephon e numbers) . 

## COPIE S O FGENERA LPERMI T CONDITION S AN D REQUIREMENT S AN D US T PROGRA M RULE S / Copie s ofth e genera l permi t t o mstal l an doperat e condition s an drequirement s an dUS T Progra mrule s an d law s ca n b e obtaine dfrom : 1 . An y o f

th e DE Q office s Hstedbelow , 2 . B y callin g th e US T HELPLIN Eat 1-800-742-7878 , 3 . Sen da

n e-mai l t o tanks.info(3>cleq.state.oru s o r 4 . Downloadin g fi-omth e US T hom e pag e at : 

### http://www.deq.state.or.us/lq/tanks/ust/index.ht m
NORTHWES TREGION : Clackamas , Clatsop , Columbia , Multnomah , Tillamoo k

& Washingto n Countie s

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

EASTER N REGIO N /

TH EDALLE S Phone : 541-298-725 5 NORTHWES T REGIO N / PORTLAN D Phone : 503-229-526 3 WESTERN REGIO N /

COO S BA Y Phone : 541-269-272 1 WESTERN REGIO N /

EUGEN E Phone : 541-686-783 8 US T HELPLIN E(I N OREGON) : WESTER N REGIO N / SALE M Phone : 503-378-824 0

1-800-742-787 8
Januar y 200 8 Pag e 4 o f 1 1 DEQ-05-LQ-016 A

## INDE X O FSELEC T STANDAR D INDUSTRIA LCODE S

STANDAR D INDUSTRIA L CODE S FO R UNDERGROUN D STORAG E hTANK S Th e Standar d Industria l Classificatio n (SIC ) Cod e wa s develope d b ytti e Federa l Govemmen t t o ai d i n gatherin g economi cstatistic s an d t o hel p compar e infonnatio n fro m differen t govemmen t agencies . Th e Departmen t o f Environmenta l Qualit y(DEQ ) use s SI C code s t o analyz e undergroun d storag e tan k location s an d t o identif yth e businesse s tha t ow n tanks . SI C code s defin e industrie s accordin g t o thei reconomi cstructure . The yclassif ybusinesse s bythei rmai n activitie s an d othe rmeasure s o f economi cactivity . (Thes e SI C code s ar e NO T th e sam e a s thos e use d o n ta xforms . Pleas e refe rt o thi s lis t fo rth e con-ec t SI C code) . DE Q ha s determine d tha t thi s lis t o f SI C code s wil l describ e man yo f th e businesse s tha t hav e undergroun d storag e tank s i n Oregon . I fyou rbusines s i s no t listed , th e complet e lis t o f SI C code s ca n b e foun d i n th e referenc e sectio n o f you rloca l libraryi n th e "Standar d Industria l Classificatio n Manual " fo r1987 . Pleas e us e th e 198 7 manua l sinc e i t list s th e correct , revise d SI C codes . Pleas e us e th e FOU R digi t cod e tha t describe s th e mai n activit yo f you rbusiness . Fin d th e con-ec t division , bein g carefu l whe n selectin g manufacturing , wholesal e o rretail . (Ther e ar e simila rcode s i n eac h o f thes e categories. ) The n fin d th e majo rgrou p tha t describe s you r business . Th e fOW ? digi t cod e should b e liste d withi n tha t majo rgroup . Fo rassistance , pleas e contac t th e US TComplianc e Section , (503 ) 229-6652 .

DIVISIO N A- AGRICULTURE , FORESTR Y& FISHIN G CROP S 011 1 Wheat-Cas h Grain s 013 9 Fiel d Crop s -Alfalfa , Clover , Gras s Seed , Hop s 016 1 Vegetable s An d Melon s 017 2 Grape s 017 3 Tre e Nut s - Filberts , Walnut s 017 5 Deciduou s Tre e Fruit s -Apples , Apricots , Chemes , Peach , Pear , Plum , Prun e 018 1 Ornamenta l Floricultur e & NurseryProduct s 018 2 Foo d Crop s Grow n Unde rCove r- Bea n Sprouts , Greenhouses , Mushroom s 019 1 Genera l Farm s - Crop s LIVESTOC K 021 1 Bee fCattle-Feedlot s 821 2 . Bee fCattle , Excep t Feedlot s P21 3 Hog s '021 4 Shee p & Goat s 021 9 Genera l Livestock , Excep t Dair y& Poultr y 024 1 Dair

yFann s 025 1 Broiler , Frye r& Roaste rChicken s 025 2 Chicke n Egg s 025 3 Turi<eys & Turi<eyEgg s 025 4 PoultryHatcherie s 027 9 Anima l Specialtie s - Othe r(Be e Farms , Ca t Farms , Do g Farms , Hone yProduction ) 029 1 Genera l Farni s - Livestoc k AGRICULTURA L SERVICE S 071 1 Soi l Preparatio n - Fertilizing , Plowin g 072 1 Cro p Planting , Cultivatio n & Protectin g 072 2 Cro p Harvestin g - Machin e FORESTR Y 081 1 Timbe rTract s - Christma s Trees , Tre e Fami s 083 1 Fores t Nurserie s 085 1 Fores t Service s 092 1 Fis h Hatcherie s DIVISIO N B - MININ G tl/tlNlN G & QUARRYIN G 142 9 Crushe d & Broke n Ston e 144 2 Constmctio n San d & Grave l DIVISIO N C - CONSTRUCTIO N BUILDIN G CONSTRUCTIO N 152 1 Genera l Contractor s - Singl e Famil yHouse s 152 2 Gen . Contractor s - Residentia l 153 1 Operativ e Builder s 154 1 Gen . Contractor s - Industria l Building s & Warehouse s 154 2 Gen . Contractor s - Nonresidentia l Building s HEAV YCONSTRUCTIO N - NO TBUILDING S 161 1 Hi g hwa y& Stree t Constructio n 162 2 Bridge , Tunnel s & Elevate d Highway s 162 3 Water , Sewer , Pipelin e & Communication s & Powe rLin e Constructio n 

# 1 SPECIA L TRAD E CONTRACTOR S |71 1 Plumbing , Heatin g & Ai rConditionin g 172 1 Paintin g & Pape rHangin g 173 1 Electrica l Wori < 174 1 Masonr

y& $tonewori < 174 2 Plastering , Drywal l & Insulatio n Wori < 174 3 Tile , Marble s Mosai cWari < 175 1 CarpentryWori < 175 2 Floors , Othe r 176 1 Roofing , Sidin g & Shee t Meta l 177 1 Concret e Wori < 178 1 Wate rWel l Drillin g 179 1 Stmctura l Stee l Erectio n 179 3 Glas s & Glazin g 179 4 Excavatio n Wori < 179 5 Wreckin g & Demolitio n 179 6 Installatio n O rErectio n O f Buildin g Equipment , Othe r 179 9 Specia l Trad e Contractors , Othe r(Awnin g Installation , Dewaterin g Contractors , Hous e

Moving , Steeplejack s & Weathe rStripping )

DIVISIO N D - MANUFACTURIN G FOO D PRODUCT S •202 1 Creamer

yButte r 202 2 Chees e 202 4 Ic e Crea m 202 6 Mil k 203 2 Canne d Specialtie s 203 3 Canne d Emits , Vegetable s & Presen/e s 203 4 Drie d Emits , Vegetable s & Soup s 203 5 Pickle d Emit s & Vegetable s 203 7 Froze n Emit s & Vegetable s 204 1 Flou r& Othe rGrai n Mil l Product s 204 7 Do g & Ca t Foo d 205 1 Brea d & Baker

y 208 2 Mal t Beverage s 208 4 Wines , Brand y& Brand ySpirit s 208 5 Distille d & Blende d Liquor s 208 6 Soft Drink s LUti/IBE R & WOO D PRODUCT S 241 1 Loggin g 242 1 Sawmill s & Planin g Mill s 242 6 Hardwoo d Dimensio n & Floorin g Mill s 243 1 Millwori < 243 4 Woo d Kitche n Cabinet s 243 5 Hardwoo d Venee r& Plywoo d 243 6 Softwoo d Venee r& Plywoo d 244 8 Woo d Pallet s & Skid s 245 2 Prefabricate d Woo d Building s 249 1 Woo d Preservin g PAPE R SALLIE D PRODUCT S 261 1 Pul p Mill s 262 1 Pape rMill s 263 1 Papertjoar d Mill s 265 3 Cormgate d Boxe s 265 6 Sanitar

yFoo d Container s 267 3 Plastic , Foi l & Coate d Pape rBag s 267 4 Uncoate d Pape rBag s PRtNTtNG . PUBLISHING , & ALLIE D INDUSTRIE S 271 1 Newspaper s 272 1 Periodical s 273 1 Books 273 2 Boo k

Printin g 275 2 Commercia l Printin g - Lithographi c 275 4 Commercia l Printin g - Gravur e 276 1 Manifol d Busines s Fonm s 278 9 Bookbindin g 279 1 Typesettin g CHEMICAL S i ALLIE D PRODUCT S 281 2 Alkalie s & Chlorin e 281 3 Industria l Gase s 281 6 Inorgani cPigment s 281 9 Industria l Inorgani cChemicals , Othe r 282 1 Plastic s 282 2 . Syntheti cRubbe r 283 3 Medicina l Chemical s & Botanica l Product s 283 4 Pharmaceutica l Preparation s 284 1 Soa p & Othe rDetergent s 284 2 - Cleaning , Polishin g & Sanitatio n Preparation s 285 1 ' Paints , Vamishes , Lacquer s 286 9 Industria l Organi cChemical s 287 3 Nitrogenou s Fertilizer s 287 4 - Phosphati cFertilizer s 287 9 Pesticide s Januar y 200 8 Pag e 5 o f 1 1 DEQ-05-LQ-016 A

## INDE X O FSELEC T STANDAR D INDUSTRIA LCODE S

289 3 Printin g In k PETROLEU M REFININ G & REL ATE D INDUSTRIE S 291 1 Peti-oleu m Refinin g 295 1 Asphal t Pavin g Mixture s RUBBE R S MISCELLANEOU S PLASTIC S 301 1 Tire s 308 4 Plastic s Pip e 308 5 Plastic s Bottle s PRIMAR YMETA L INDUSTRIE S 331 2 Stee l Wori< s 3321 . Gray& Ductil e Iro n Foundrie s 333 4 Primar

yProductio n O fAluminu m 334 1 Secondar

ySmeltin g & Refinin g - Nonfen-ou s 336 5 Aluminu m Foundrie s 336 6 Coppe rFoundrie s DIVISIO N E -TRANSPORTATION , COMMUNICATIONS , ELECTRIC , GA S & SANITAR YSERVICE S RAILROA D TRANSPORTATIO N 401 1 Railroads , Line-Hau l Operatin g 401 3 Railroa d Swritching/Temiinal s LOCA L TRANSI T& HIGHWA YPASSENGE R TRANSPORTATIO N 411 1 Loca l & Suburba n Transi t 412 1 Taxicab s 413 1 Intercit y& Rura l Bu s Transportatio n 415 1 Schoo l Buse s 417 3 Termina l & Servic e Facilitie s MOTO R FREIGH TTRANSPORT ATIO N & WAREHOUSIN G 421 2 Loca l Truckin g Withou t Storag e 421 3 Tmcking , No t Loca l 421 4 Loca l Truckin g Wit h Storag e 421 5 Courie rService s 422 1 Ear n Produc t Storag e 422 2 Refrigerate d Warehousin g & Storag e 422 5 Genera l Warehousin g & Storag e 423 1 Tennina l & Maintenanc e Facilitie s - Freigh t Transportatio n 431 1 Unite d State s Posta l Servic e 449 3 Marina s TRANSPORT ATIO N B YAI R 451 2 Ai rTransportatio n 451 3 Ai rCourie rService s 458 1 Airports , Flyin g Field s & Terminal s COMMUNICATION S 481 2 Radiotelephon e 481 3 Telephon e 483 2 Radi o Broadcastin g Station s 483 3 Televisio n Broadcastin g Station s ELECTRIC , GA S S SANITAR YSERVICE S 491 1 Elecbi cService s 492 3 Nafcira l Ga s Distiibutio n 494 1 Wate rSuppl y, 495 2 Sewerag e System s 495 3 Refus e System s 497 1 Irrigatio n System s DIVISIO N F - WHOLESAL E TRAD E DURABL E GOOD S 501 4 Tire s & Tube s v ^ 503 1 Lumber , Plywood , Millwori ^ & Woo d Panel s 508 2 Consfructio n & Minin g Equipmen t - Sol d T o Companie s 508 3 Farn i & Garde n Machiner y& Equipmen t - Sol d T o Famn s & OUie rBusinesse s 508 4 Industiia l Machiner y& Equipmen t - Sol d T o Companie s 508 5 Industria l Supplie s 509 3 Scra p & Wast e Material s NONDURABL E GOOD S 514 1 Groceries , Genera l Lin e 514 2 Package d Froze n Food s 514 3 Dair

yProduct s 514 4 Poultr

y& Poulb yProduct s 514 6 Fis h 8 i Seafoo d 514 7 Meat s & Mea t Product s 514 8 Fres h Emit s & Vegetable s 517 1 Peti-oleu m Bul k

Station s & Terminal s 517 2 Petroleu m & Peft-oleu m Product s - No t Terminal s 518 1 Bee r& Al e 518 2 Win e & Distille d Alcoholi cBeverage s 519 1 Farn i Supplie s DIVISIO N G-RETAI L TRAD E BUILDIN G MATERIALS , HARDWAR E GARDE N SUPPL YS MOBIL E HOM E DEALER S 521 1 Lumbe r& Ottie rBuildin g Material s 525 1 Hardwar e Store s 526 1 Retai l Nurseries , Law n & Garde n Suppl yStore s ) 527 1 Mobil e Hom e Dealer s GENERA L MERCHANDIS E STORE S 531 1 Departmen t Store s 533 1 Variet yStore s FOO D STORE S 541 1 Grocer

yStore s ^ 543 1 Emi t & Vegetabl e Mari^ets 545 1 Dair

yProduct s Store s AUTOMOTICEDEALER S S GASOLIN E SERVIC E ST ATION S 551 1 Moto rVehicle s Dealer s (Ne w& Used ) 552 1 Moto rVehicle s Dealer s (Use d Only ) 553 1 Aut o An d Hom e Suppl yStore s 554 1 Gasolin e Servic e Station s 556 1 Recreationa l Vehicl e Dealer s 557 1 Motorcycl e Dealer s E ATIN G & DRINKIN G PLACE S 581 2 Eatin g Place s 581 3 Drinkin g Place s (Alcoholi cBeverages ) 598 3 Fue l Oi l Dealers

DIVISIO N H - FINANCE , INSURANC E & REA L ESTAT E DEPOSITOR YINSTITUTION S 602 1 Nationa l Commercia l Banks 602 2 Stat e Commercia l Banks 602 9 Ottie rCommercia l Banks 603 5 Saving s Instihjtions , Federall yChartere d 606 1 Credi t Union s REA L ESTAT E 651 2 Operator s O f Nonresidentia l Building s 651 3 Operator s O fApartmen t Building s 651 5 Operator s O f Residentia l Mobil e Hom e Site s 653 1 Rea l Estat e Agent s & Manager s 655 2 Lan d Subdivider s & Developer s DIVISIO N 1-SERVICE S HOTEL S ROOMIN G HOUSE S CAMP S < S OTHE R LODGIN G PLACE S 701 1 Hotel s & Motel s - Includin g Recreatio n Facilitie s 703 2 Sportin g & Recreationa l Camp s 703 3 Recreationa l Vehicl e Pari( s & Campsite s - Campground s 721 6 Drydeaner s AUTOMOTIV E REPAIR , SERVICE S S PARKIN G 751 3 Tmc k

Renta l & Leasin g 751 4 Passenge rCa rRenta l 751 5 Passenge rCa rLeasin g 752 1 Automobil e Paridn g 753 2 Top , Bod y& UpholsteryRepai rShop s 753 4 Tir e Retreadin g & Repai rShop s 753 7 Automotiv e Transmissio n Repai rShop s 753 8 Genera l Automotiv e Repai rShop s 754 2 Caiwashe s 754 9 Lubricatin g Servic e & OUie rAutomotiv e Services , Excep t Repair/Canwashe s AMUSEMENTS , RECRE ATIO N SERVICE S 799 2 Publi cGol fCourse s 799 6 Amusemen t Paries 799 9 Amusemen t & Recreatio n Services , Ottie r- Paries , Fairgrounds , Da yCamps , Mope d Rental , Sk i Lifts , Touris t Atb-action s 806 2 Genera l Medica l & Surgica l Hospital s 598 3 Fue l Oi l Dealers EDUCATIONA L SERVICE S 821 1 Elementar

y& SecondarySchool s 822 1 Colleges , Universitie s & Professiona l School s 823 1 Librarie s 871 1 Engineerin g Service s

DIVISIO N J - PUBLI C ADMINISTRATIO N 911 1 Executiv e Offices—Office s O f Cities , Counties , Mayors , Etc . 912 1 Legislativ e Bodies—CityCouncils , CountyCommissioners , Etc . 919 9 Genera l Govemment—OUie rGovemmen t 922 1 Polic e Protectio n 922 3 Correctiona l Instihjtion s 922 4 Fir e Protectio n 951 2 Land , Mineral , Wildlif e & Fores t Conservatio n 962 1 Regulatio n & Administi-atio n O fTransportati'onProgram s - Por t Auttioritie s Januar y 200 8 Pag e 6 o f 1 1 DEQ-05-LQ-016 A' ^ ^

^ 

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

### OREGO N DEPARTMEN TO F ENVIRONMENTA L QUALIT Y

UNDERGROUN D STORAG E TAN KPROGRA M GENERA L PERMI TREGISTRATIO N FOR M



### AN D 30-DA YNOTIC E FO RDE Q US EONL Y Dat e Rec' d CkNo . Amt Rec' d$ ' Deposi t US T Permi t

Fee s

• . \/'.•\\
- '.
- . W . • \

-= : y^ .



### FACILIT Y NAME : FACILIT Y ADDRESS :
CITY , STATE& ZIP : PHONE : SI C CODE : FACILIT Y NUMBER : (I f known ) 

### GENERA LPERMI T REGISTRATIO N FE E Fo r ne w tanks , aregistratio n fe e o f $135.0 0 pe r

tan k an da n installation fee o f $40 0 pe r tan k i s du e for

th e curren t

year . Fo r

multi-chambere do r

multi-compartmen t

tanks , th e registratio n fe e i s $135.0 0 an dth e installatio n fe e i s $40 0 for eac hchambe r

or compartment . T o calculat e th e registratio n fe e owe dpleas e fill i n th e blank s below : Numbe r o f ne w tank s o r

compartment s X $535.0 0 = ^ Tota l Fe e Du e Thi s registratio n fe e wil l als o serv e a s th e first armua l complianc e fe e for

th e remainin g portio n ofth e year

i n whic hth e registratio n for mi s submitted . Januar y 200 8 Pag e 7 o f 1 1 DEQ-05-LQ-016 A

# GENERA LPERIMI T REGISTRATIO N FORI M 

# T O INSTAL LAND OPERAT EUST s

1 . TAN K

OWNER * a s registere dwith th e Secretary o f

State , Corporation s Divisio n
Nam e o f Official (Pleas e Print )

' • ' 1 • Signatur e o f

Official Dat e —1: = • —._^^- . - — Mailin g Addres s (Pleas e Print )

City , Stat e an dZi p Cod e
Are aCod e an dtelephon e Numbe r I wil l instal l an doperat e th e UST s describe do n th e Notificatio n an dDescriptio n o f Undergroun dStorag e Tan k System s page s in accordanc e wit hth e condition s an drequirement s ofth e applicabl e genera l permits .

^ 2 . PERMITTEE * a s registere dwithth e Secretary o f

State , Corporation s Divisio n
Nam e o f Official (Pleas e Print ) Signatur e o f

Official Dat e ....-.:;:. . . ' Mailin g Addres s (Pleas e Print )

City , State an dZi p Cod e
Are aCod e an dTelephon e Numbe r I will instal l an doperat e th e UST s describe do n th e Notificatio n an dDescriptio n o f Undergroun dStorag e Tan k System s page s in accordanc e withth e condition s an drequirement s o f th e ap^icabl e genera l permits .

r . • . . " • 

### 3 . PROPERT Y OWNE Ri s nam e tha t appear s o n th e County dee drecor dfo r thi s property . f^am e o f Official (Pleas e Print ) Signatur e o f

Official Dat e Mailin g Addres s (Pleas e Print ) / City , State an dZi p Cod e
Are aCod e an dTelephon e Numbe r * I f thi s facilit y o r tanks ar e o-wne db y aperson , o

r operatedb y apermittee , tha

t i s abusines s registeredwit

hthe Secretar y of State , Corporation s Division , pleas e us e tha t lega l busines s nam

e fo r purpose s o

f registering thes e UST s wit hthe Department . Pleas e retur n complete dpage s 7 & 8 , th e Notification an dDescriptio n o f Undergroun dStorag e Tan k System s page s 9,1 0 an d11 , an dapplicabl e registratio n fe e to : DE Q - Busines s Offic e 81 1 S We" " Avenu e Portland , Orego n 9720 4 Januar y 200 8 Pag e 8 o f 1 1 DEQ-05-LQ-016 A

### Notificatio n an d Descriptio n o f Undergroun d Storag e Tan k System s TYP E O F OWNE R INDIAN COUNTR Y I I Federa l Governmen t I : I Stat e Governmen t I I Loca l Governmen t I I Commercia l I I Privat e Tank s ar e locate d o n lan d withi n a n India n I I Reservatio n o ro n trus t land s outsid e ^~ ^ reservatio n boundaries . Tank s ar e owne d b ya Nativ e America n natio n o rtribe . 

# D Trib e o rNation :

TYP E O F FACILIT Y Ga s Statio n Petroleu m Distributo r I I Ai rTax i (Airline ) I J Aircraf t Owne r I I Aut o Dealershi p I I Railroa d I I Federa l - Non-Military I j Federa l - Military 

# D 

# • Industria l Contracto r I I Trucking/Transport I I Utilitie s I I Residentia l I I Far m I I Othe r(Explain ) FINANCIA L RESPONSIBILIT Y 

# n wil l mee t th e financia l responsibilit yrequirement s i n accordanc e wit h OA R 34 0 - Divisio n 15 1 Chec k Al l tha t Appl y

^ 1 Pollutio n Liabilit yInsuranc e ^ H j Sel f Insuranc e I Exemp t (Federa l o rStat e Government ) | _ J Lette ro f Credi t I I Suret yBon d I I Guarante e I I Loca l Governmen t



### Th e financia l responsibilit yrequirement s ar e designe d t o mak e sur e tha t th e tan k owner , propert yowne ro r permitte e ca n pa yth e cost s o f cleanin g u p leak s an d compensatin g thir d partie s fo rbodil yinjuryan d propert ydamag e cause d b yleakin g USTs . Aplai n languag e summaryofth e financia l responsibilit y requirement s ca n b e downloade d fro m th e Interne t a t http://www.epa.gov/swerust1/pubs/dollars.htm . Fo ra lis t o f know n insuranc e provider s g o t o http://www.epa.gov/swerust1/pubs/inslist.htm . CONTAC TPERSO N I N CHARG E O F TANK S Name : Jo b Title : Address : Phon e Numbe r(Includ e Are a Code) :

CERTIFICATIO N (Rea d an d sig n afte rcompletin g al l section ) 1 certif yunde rpenalt yo f la wtha t 1 hav e personall yexamine d an d a m familia rwit h th e informatio n submitte d i n thi s an d al l attache d documents, an d tha t base d o n m yinquiryo f thos e individual s immediatel yresponsibl e fo robtainin g th e information , 1 believ e tha t th e submitte d informatio n i s true , accurate , an d complete . Nam e an d officia l titl e o f owne ro rowner' s authorize d representativ e (Print ) Signatur e Dat e Signe d

Januar y 200 8 Pag e 9 of 1 1 DEQ-05-LQ-016 A

### NOTIFICATIO N AN D DESCRIPTIO N O F UNDERGROUN D STORAG E TAN KSYSTEM S ^ (Complet e fo reac h tan k a t thi s location ) ^ B Tan k Identificatio n Numbe r Tan k No . Tan k

No . Tan k

No . Tan k

No . Tan k

No . 1 . Statu s o f Tan k

(Chec k (V ) onl yone ) Currentl yI n Us e Temporaril yOulio f Us e Permanentl yOu t o f Us e 2 . Dat e o f Installatio n (mont h & year ) 3 . Estimate d Tota l capacit y(gallons ) 4 . Materia l o f constructio n (Chec k (V ) al l Asphal t Coate d o rBare Stee l CathodicaU yProtecte d Steel , Epox yCoate d Stee l Composit e (Stee l wit h Fiberglass ) Fiberglas s Reinforce d Plasti c

Line d Interio r Doubl e Walle d Polyethylen e Tan k

Jacke t Concret e Excavatio n Line r Unknow n : Qthi rIVIaterial , Plias e SpiBcif y Ha s Tan k bee n Repaired ? Chec k (V ) Boxi f Ye s Dat e o f Ripavi i 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 ^ ^^i 

# 1 1 tha t apply ) 1 1 1 

# I I I I 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 . Pipin g - Materia l (Chec k (V ) al l tha t apply ) Bare Stee l Bare Stee l Wrappe d Galvanize d Stee l Fiberglas s Reinforce d Plasti c

Coppe r CathodicaU yProtelte d Doubl e Walle d Secondar

ycontainmen t Unknow n No t i n Contact Wit h Soi l Othe rMaterial , Pleas e Specif y 6 . Pipin g - Typ e (Chec k (V ) al l tha t appl y Suctio n - n o valv e a t tan k Suctio n - valv e at tan k

Pressur e GravityFee d Ha s Pipin g bee n Repaired ? Chec k (V ) boxi f Ye s Dat e o f Repai r 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

• ^

- •
Januar y 200 8 Pag e 1 0 o f 1 1 DEQ-05-LQ-016 A

### NOTIFICATIO N AN D DESCRIPTIO N O F UNDERGROUN D STORAG E TAN KSYSTEM S (Complet e fo reac h tan k at thi s location ) Tan k Identificatio n Numbe r Tan k No . Tan k No . Tan k No . Tan k No . Tan k No . 7 . Substanc e Currentl yo rLas t Store d i n Greates t Quantit yb yVolum e (Chec k (V ) Onl yOn e Substanc e Pe rTank)

Gasolin e 

## 1 Diese l 

## J Gasoho l Kerosen e Heatin g Oi l UsediDi l Hazardou s Substanc e CERCLANam e and/o r

CA S Numbe r Mixtur e o f Substance s Pleas e SpecifyMixtur e

Othe r Pleas e SpecifyOthe r 8 . Releas e Detectio n (Chec k (V ) al l tha t Appl y Manua l Tan k

Gaugin g Tan k Tightnes s Testin g Inventor yContro l Automati cTan k

Gaugin g Vapo rMonitorin g Groundwaterj-Mbnitorin g Secondar yContainmen t Automati cLin e Lea k

Detecto r Lin e tightnes s Testin g N o Releas e Detectio n Require d (Emergenc yGenerato r/ / Fiel d Constmcte d Tanks ) 

### Othe rMetho d Allowe d b y ; Departmen t Othe rMethod , Pleas e Specify 9 . Spil l an d Overfil l Protectio n Overfil l Devic e Installe d Spil l Devic e Installe d

Januar y 200 8 Pag e 1 1 o f 1 1 DEQ-05-LQ-016 A

### « 

# 9 ^ DE Q state o f Orago n Departmen t o f Environmenta l Qualit y 

## OREGO N DEPARTMEN TO F ENVIRONMENTA L QUALIT Y UNDERGROUN D STORAG E TAN KPROGRA M 

# USTINSTALLATIO N CHECKLIS T

DE Q US T Facilit y I D # : DE Q Facilit y Address : _DE Q Facilit y Name : •Permitte e Phone : Thi s checklis t

mus t b e fille dou t

b y th e DE Q license dUS T Superviso r an dsubmitte da s part

o f th e installatio n recor di n accordanc e withOA RChapte r

34 0 - Division s 15 0 an d160 . Th e US T Superviso r mus t b e on-sit e durin g th e fieldoperation s liste dbelow . A ne w installatio n mus t

b e inspecte daminimu mo f thre e time s b y th e installe r an dal l th e requeste dinformatio n provide dt o th e DEQ . Wher e aspecifi c ite mi s "NO T APPLICABLE " t o th e situation , pleas e chec k th e N/A box . Thi s checklis t mus t b e signe db y a n executiv e officer

o f th e US T Servic e Provide r iir man db y th e license dUS T Superviso r o n pag e 6 . Th e Permitte e o r tan k owne r mus t sig n th e certificatio n statemen t o n pag e 6 . Th e las t

pag e o f thi s checklis t

contain s addresse s an dphon e number s for DE Q regiona l offices . FIRS T INSPECTIO N - PRIO RT O PLACEMEN T O FTH EUNDERGROUN D STORAG ETAN K

INT O TH EEXCAVATIO N



### # 1 . Th e tank

installe r i s license db y DE Q a s aUS T Servic e Provider . 2 . Permitte e ha s submitte dth e DE Q Genera l Permi t Registratio n For mt o Instal l an d Operat e UST s 30-day s prio r t o startin g th e installatio n wit hth e aDnronriat e genera l permi t fees . Certificat e number : - - • • ^^;: ' • :;^ : ::: • • "•'••'-' • • • • ' :••'• • '• ' 3 . Th e DE Q Regiona l Offic e wa s notifie d7 2 hour s ( 3 workin g days ) i n advanc e ofth e installation . Notificatio n lo g number : •:' : •• : : ' ; : : ' : • • ' ; •

' •.•':'.'• ' -

^ 4 . Wa s hydrocarbo n contammatio n observed ? I f so , wa s i t

reporte dt o DEQ ? Releas e lo g number : 5 . Tan k an dpipin g material s mus t compl y withOA RChapte r 34 0 - 15 0 - 0160 . 6 . Manufacturer' s specification s fo r pre-mstallatio n practice s hav e bee n followed . 7 . An y detecte ddamag e ha s eithe r bee n repaire do r

replace din amanufacturer-approve d manne r prio r t o placemen t

in th e excavation . 8 . Tank s hav e bee n pressur e teste dan dsatisf y AP I #161 5 specifications . 9 . Tan k excavatio n complies withth e standard s o f AP I #161 5 o r

PEI/R P100-2000 . 10 . Backfil l an dbeddin g material s fulfill th e tank manufacturer' s recommendations . 11 . An y require danchorin g o f tank s (ful l o r

empty ) i s in accordanc e wit hth e manufacturer' s specifications . 12 . Th e abov e requirement s hav e bee n followe dan dhnplemented . 1^'Inspectio n Dat e YE S



# n

' • r N O



# 1 1 Unknow n



# 1 1 N/ A

License dUS T Supervisor' s Signatur e Prin t Nam e Supervisor' s Licens e Numbe r Januar y 200 8 Pag e lo f 8 05-LQ-017 ASECON D INSPECTIO N - AFTE RPLACEMEN T O FUNDERGROUN D STORAG E

TANK , BU T PRIO RT O BACKFILLIN G 13 . Tan k placemen t

wa s don e in accordanc e wit hth e manufacturer' s specifications . 14 . Wa s tan k

damage dprio r

t o o r durin g placement ? SACRIFICIA LANOD ESYSTEM S 15 . Di danodes , dielectri c bushings , o r coating s mcu r

any damag e durin g installation? 16 . Damage s t o anod e connections , coating s o r tank s hav e bee n repau-e din accordanc e with th e manufacturer' s specifications . 17 . Necessary pre-packin g o n eac hanod e ha s bee n remove do r kep t intac t accordin g t o manufacturer' s instruction s and/o r eac hanod e ha s bee n properl y place din it s prepackage d

- backfil l material . IMPRESSE D CURREN T SYSTEM S 18 . Wer e th e anode s o r

th e associate dleadwire s an dmsulatio n damage ddurin g installation? 19 . Anode s hav e bee n mstalle daccordin g t o th e manufacturer' s specifications . 20 . Th e negativ e termina l ofth e rectifie r ha s bee n connecte dt o th e structur e an dth e positiv e termina l t o th e anodes . 21 . Continuity o f

th e wir e ha s bee n tested . 22 . Wa s testin g conducte dt o ensur e that cathodicaUy protecte dstructure s hav e no t bee n grounde din suc hawa y that woul dnullif

y cathodi c protectio n t o th e undergroun dstorag e tan k system ? 23 . A cathodi c protectio n tes t statio n i s installed . PIPIN G 24 . Doe s al l pipin g slop e bac k (down ) t o th e tanks ? 25 . Pipin g joint s hav e bee n assemble din accordanc e withth e pipin g an dsealan t manufacturer' s preparation , applicatio n an dassembl y instructions . 26 . Al l pipin g mstalhnen t requirement s specifie db y th e manufacture r hav e bee n followe dan d implemented . YE S 

# r r ^

- : N O Unknow n

/ N/A



# m

-)n d License dUS T Supervisor' s Signatur e 2 Inspectio n Dat e
Prin t Nam e Supervisor' s Licens e Numbe r 

# IMPORTAN T ATTAC H INFORMATIO N FO RAN Y EQUIPMEN T ASSOCIATE D WIT H TH EUS T SYSTEM S INSTALLED . THI S WIL LINCLUD EA T A MINIMUM , A LIS T O FMAJO RSYSTE M COMPONENTS , THIRD-PART Y EVALUATIONS , MANUFACTURER S CHECKLISTS , PHOTOGRAPHS , AS-BUILTS , AN D I FAVAILABL EFIR EAUTHORIT Y SIGNOF FO RPRESSUR ETES T RECORDS .

Januar y 200 8 Pag e 2 of 8 05-LQ-017 ATHIR D INSPECTIO N - AFTE RBACKFILLIN GAN D PRIO RT O OPERATIO N

27 . Backfil l materia l an dinstallatio n complete da s pe r tan k manufacturer' s specifications . ^28 . Al l electrica l equipment , wirin g an drelate dinstallation s hav e bee n don e in accordanc e wit hNFP A 7 0 an dNAC ER P028 5 - 2002 . 29 . Pipin g ha s bee n pressur e teste dan dsatisfie s AP I #161 5 specifications . 30 . Spil l protectio n device s hav e bee n properl y installed . 31 . Wa s pipm g damage ddurin g installatio n o r backfilling ? 32 . Non-corrosio n resistan t pipin g ha s bee n cathodicaU y protected . 33 . Pip e coatin g (i f

applicable ) ha s al l existin g damag e (holidays , chips , scratches , etc. ) repaire din accordanc e withth e manufacturer' s specifications . 34 . Pipin g i s electricall y isolate dfi'omdispensers , structures , tank s an dothe r pipe s o r conduits . 35 . Pipin g ha s electrica l continuity . 38 . Cathodi c protectio n mstallatio n meet s AP I #163 2 o r NAC ER P028 5 - 200 2 standards . 36 . Hav e dissimilar

metal s bee n connecte dtogether ? 37 . Al l dielectri c bushing s an dfitting s ar e compatibl e withth e liqui dstore dan dth e operatin g pressur e ofth e tank

system . 38 . Protectio n i s provide dfor thos e gauges , monitorin g devices , an dothe r system s which , whe n subjec t

t o failure b y corrosion , may caus e areleas e o r impai r th e operatio n o f

a monitorin g system . 39 . Adequat e clearanc e ha s bee n provide dbetwee n pipin g an dtrenc hwalls , conduit , monitorin g well , utilities , nearb y structures , an dothe r syste mcomponent s followin g NFPA , AP I o r

PE I standards . 40 . Were ther e any leak s o r evidenc e o f

leakag e in th e assemble dpipin g at any connectio n o f flexible connector s unde r eithe r pressur e testin g o r

norma l operatin g conditions ? 41 . Bothoverfil l protectio n an dlea k detectio n monitorin g syste mrequhement s o f OA R340
- 150-016 0 hav e bee n me t

an dare functionin g properly . 42 . Tan k deflectio n measurement s for FR Ptank s hav e bee n remeasure dat thi s poin t an d remai n withi n th e acceptabl e limit s ofth e manufacturer' s speciflcations. 43 . Cathodi c protectio n system s teste dan dfoun dt o b e providin g adequat e protection ? 44 . I s afollow-u p cathodi c protectio n inspectio n schedule do r planne dat

th e require dinterval ? 45 . Intema l an dextema l monitorin g an dgaugin g system s are workin g properly . 46 . On e cop y ofth e a s buil t drawing s ofth e mstallation i s attache dt o thi s checklist . 47 . Majo r

US T syste mcornponen t

lis t i s attached . (May includ e receipt s o r invoices) . 48 . A cop y ofth e monitorin g syste mthir dparty evaluatio n i s attache d(May includ e aon e pag e summary o r

th e firs t pag e ofth e complet e evaluation) . 49 . Copie s ofth e manufacturer' s checklist s ar e attached . 50 . Photograph s attached . 51 . Fir e authority signof

f an do r copies o f pressur e tes t

result s ar e attached . YE S N O



# 1 1 Unknow n



## • M N/ A 

# 1- 1 1

1

License dUS T Supervisor' s Signatur e Prin t Nam e 3^' * Inspectio n Dat e Supervisor' s Licens e Numbe r Januar y 200 8 Pag e 3 of 8 05-LQ-017 A

### US T an dPipin g Equipmen t Informatio n Syste m# Tan k Typ e Tan k Manufacture r Tan k Mode l # Produc t Volume , gal . Pip e Typ e Pip e Manufacture r Pip e Mode l # 1

• ' ; 2 3

•'''
- - ^ • : :^ ; 4



### US T Releas e Detectio n Equipmen t Informatio n Chec k a t leas t on e Releas e Detectio n Metho dfor eac htank : Tan k # Automati c Tan k

Gaugin g Syste m Interstitia l Monitorin g (wit hsecondar y containment ) Groundwate r

Monitorin g ' Vapo r Monitorin g Inventor y Contro l an dTan k Tightnes s Testin g Manua l Tan k

Gaugin g Onl y Manua l Tan k

Gaugin g an dTan k

Tightnes s Testin g Othe r Releas e Detectio n Method , suc ha s SI R(pleas e specify ) # 1 # 2 #3 # 4 1



### Spil l Preventio n Equipmen t Informatio n Tan k # Spil l Bucke t Catchmen t

Basi n N o Spil l Preventio n Requiremen t # 1 # 2

• •-- • #3 . 4 1



### Januar y 200 8 Pag e 4 o f 8 05-LQ-017 APipin g Releas e Detectio n Method s an dEquipmen t

ressurize dPipin g Method s hec k a t leas t on e Releas e Detection metho dfro mSection A "AND " a

t leas t on e methodfi-omSectio

n B fo r piping system : Sectio n A Pipin g system s Automati c Lin e Lea k

Detecto r -Flo w Restricto r

(mechanical ) Automati c Lin e Lea k

Detector-Flo w Shutof

f (electrical ) Automati c Shutof

f Devic e Senso r wit hContinuou s Alar m # 1 # 2 # 3 # 4 1

• •

Sectio n B Pipin g System s Annua l Lin e Tightnes s Tes t Monthl y Monitoring * # 1 \" ' # 2 # 3 . . # 4 1

# uctio n Pipin g Method s hec k a t leas t on e Releas e Detection metho ds below :

Pipin g System s Lm e Tighmes s Testin g Every Thre e Year s Monthl y Monitormg * N o Releas e Detectio n Require dFo r "Saf e Suction " * * # 1 # 2 # 3 # 4 1

* Monthl y Monitorin g fo r pipin g include s Interstitia l Monitoring , Vapo r Monitoring , Groundwate r Monitoring , an dSI R(no t pressure) . * * N o releas e detectio n require donl y i f i t ca n b e verifie dtha t

yo u hav e a"saf

e suction " pipin g syste mwit hth e followin g characteristics : 1 ) Onl y on e chec k

valv e pe r

lin e locate ddirectl y belo w th e dispenser ; 2 ) Pipin g slopin g bac k

t o th e tank ; an d 3 ) Syste mmus t

operat e unde r

atmospheri c pressure . Overfil l Preventio n Device s Chec k a t leas t on e Releas e Detection metho ds below :

Tank # Overfil l Alarm Automati c Shutof

f Devic e Bal l Floa t Valv e N o Overfil l Preventio n Require d # 1

^Z:'\: Z mm

m # 2 # 3 # 4 1

Januar y 200 8 Pag e 5 of 8 05-LQ-017 A

### INSTALLER' S OATH : I certif y tha t I wa s th e Orego n DE Q license dsuperviso r presen t o n sit e durin g th e abov e liste dtan k

installatio n activitie s an dt o th e bes t o f my knowledg e the y hav e bee n conducte di n complianc e withal l stat e an dfederal laws , regulation s an dindustry standard s an dprocedure s pertainin g t o undergroun dstorag e tanks . I further certif y tha t th e informatio n containe di n thi s report an dchecklis t

i s tru e t o th e bes t o f my belie f

an dknowledge . Installer : (Prin t Name ) (Signature ) Position: Company : . Date : US T Servic e Provide r

Firm , Executiv e Officer : (Prin t Name ) (Signature ) (Date )

PERMITTE EO ROWNER' S FINANCIA LRESPONSIBILir Y INFORMATIO N SECTION : Th e permitte e o r

tan k owne r ha s financial responsibility , i f applicable , i n accordanc e with4 0 CF RPart 28 0 - Subpart H a s adopte dpursuan t

t o OA R340-151-0015 . Pleas e specif y th e type o f

financial mechanis mbein g use dt o compl y withthi s requiremen t an dsubmi t

acop y ofth e require ddocumentatio n specifie di n th e rules . NOTE : I f

pollutio n liabilit y insuranc e i s you r mechanis mo f

choice , yo u mus t

submi t acop y ofth e Certificat e o f

Endorsemen t

o r Certificat e o f

Insuranc e require db y Sectio n 280.9 7 (b)(1 ) o r (b)(2) , respectively . A n ACOR D doe s no t satisf y th e proo f

o f insuranc e requirement . I I Permitte e [ I Tan k Owne r Pleas e chec k

('' ) wh o i s providin g financia l responsibility . Metho do f

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

• • : Insurer : •

• ' • : ' : • ' Polic y Number : •• • ' . /

./: .

US T FACILIT Y PERMITTE EO RTAN K OWNE R INSTALLATIO N CERTIFICATIO N STATEMENT : I hereb ycertif ytha t th e informatio n provide d o n thi s for m concernin g th e installatio n statu s o f m y undergroun d storag e tan k system(s ) I s accurate . Prin t Nam e Signatur e (Tequired ) Dat e Pleas e note : I n accordance wit h OR S 466.76 5 an d OA R 340-150-013 5 (2) , yo u are require d t o cooperat e full ywit h inspections , monitorin g an d testin g conducte d b yth e Department , a s wel l as requests fo rdocumen t sutimisslon , testin g an d monitorin g pursuan t t o sectio n 900 5 o f Subtitl e I of th e Resource Conservatio n an d Recover yAct , as amended . Th e Informatio n yo u hav

e submitte d I s subjec

t t o audi t an d verificatio n b yth e Department' s Undergroun d Storag e Tan k Compliance Inspectors . Afals e certificatio n ma yresul t I n enforcemen t actio n bein g take n b yth e Department .
Januar y 200 8 Pag e 6 o f 8 05-LQ-017 A

### DE Q REGIONA LUS EON LY US T FACILIT Y I D NUMBER: , DE Q REGIONA LINSPECTION S AN D REVIEW : Thi s for mmay b e use db y DE Q Inspector s for oversigh t purposes . A DE Q inspecto r i s no t require dt o inspec t

th e installation . A DE Q inspecto r may o r ma y no t b e o n sit e o r

availabl e durin g al l ofth e inspection s liste do n thi s form . I n th e cas e o f a n oversigh t inspection , th e DE Q inspecto r shoul dchec k

al l boxe s tha t

ar e appropriat e for

th e inspection(s) . Thi s sectio n o f th e for mwil l b e use db y DE Q regiona l staf f a s verificatio n o f

regiona l review . Checklis t ha s bee n reviewe dan di s complet e Initia l Checklis t attachment s submitte dan dcomplet e Initia l Installe r certificatio n complet e Initia l . Ful l complianc e inspectio n complete dYe s N o Partia l complianc e inspectio n complete dYe s N o Passe dcomplianc e inspectio n Ye s N o N/A _ Notes :

DE Q Inspector : (Pleas e Print ) DE Q Inspector' s Signature : Date : DE Q H Q STAF FUS EONL Y Thi s sectio n ofth e for

muse da s verificatio n confirmatio n o f financial responsibility . Chec k al l tha t apply . Q Pollutio n Liability Insuranc e Q Lette r o f Credi t GGuarante e Q Sel f Insuranc e Q Surety Bon dQ Loca l Govemmen t Q Exemp t

(Federa l o r

State Govemment )

DE Q Staf f Signature : Date:__

Januar y 200 8 Pag e 7 o f 8 05-LQ-017 ANORTHWES TREGION : Clackamas , Clatsop , Columbia , Multnomah , Tillamoo k & Washingto n Countie s
WESTER N REGION : Benton , Coos.Curry , Douglas , Jackson , Josephine , Polk , Lane , Lincoln , Linn , Mario n & Yamhil l Countie s EASTER N REGION : Baker , Crook , Deschutes , Gilliam , Grant , Harney , Hoo d River , Jefferson , Klamath , Lake , Malheur , Morrow , Sherman , Umatilla , Union, Wasco , Wheele r & Wallow a Countie s



## Thi s for mmus t

b e maile dt o th e appropriat e DE Q Regiona l Offic e withi n 3 0 day s afte r th e installatio n i s complete . Fo r information , cal l th e appropriat e DE Q Regiona l Offic e o r th e tol l fre e numbe r

1-800-742-7878 .

TH EDEPARTMEN T O FENVIRONMENTA LQUALIT Y US T PROGRA M REGIONA LOFFIC EI N WHIC H YOU RFACILIT Y I S LOCATE D EASTERN REGION/TH EDALLE S 400 ESCENI C DRIVE , #30 7 TH EDALLES , O R9705 8 FAX : 541-298-733 0 Phone : 541-298-725 5 NORTHWES T REGIO N 202 0 S W4T H AVENUE , SUIT E40 0 PORTLAND , O R9720 1 FAX : 503-229-694 5 Phone : 503-229-526 3 WESTERN REGION /

COO S BA Y 38 1 N . SECON D STREE T COO S BAY , O R9742 0 FAX : 541-269-798 4 Phone : 541-269-272 1 WESTERN REGIO N /

EUGEN E 110 2 LINCOL N STREET , SUIT E21 0 EUGENE , O R9740 1 FAX : 541-686-755 1 Phone : 541-686-783 8 US T HELPLINE : 1-800-742-787 8 (Tol l Fre e in Oregon ) WESTER N REGIO N / SALE M 750 FRON T STREE T NE , SUIT E120 SALEM , O R9730 1 FAX : 503-373-794 4 Phone : 503-378-824 0

\ J

Januar y 200 8 Pag e 8 of 8 05-LQ-017 A

# ^o ^

stat e of Orego n Departmen t o f Environmenta l Qualit y 

## OREGO N DEPARTMEN TO F ENVIRONMENTA L QUALIT Y UNDERGROUN D STORAG E TAN KPROGRA M GENERA L PERMI TREGISTRATIO N FOR M

AN D 30-DA YNOTIC E

• 

### Complet e on e genera l permi t registratio n packag e fo reac h separat e

facilit yyo u ar e registering . Eac h registratio n packag e include s th e registratio n for m (page s 7 & 8 ) wit h signatur e blocks , a fe e matri xt o calculat e th e require d registratio n fe e (pag e 7 ) an d th e notificatio n an d descriptio n o f undergroun d storag e tan k system s (page s 9 , 1 0 & 11) . I f yo u ar e installin g mor e tha n fiv e (5 ) tanks , pleas e mak e additiona l copie s ofth e descriptio n page s (page s 9 , 1 0 & . 11 ) an d lis t th e additiona l tank s o n th e copie s yo u make . Yo u mus t cal l you rregiona l offic e t o receiv e authorizatio n t o procee d wit h th e Installatio n 7 2 hour s prio rt o beginnin g work . Se e pag e 4 fo roffic e locations . CHECKLIS T ^ B e sur e signature s are provide dfor th e tan k owner , permitte e an dproperty owner , eve n wher e on e perso n fill s al l thre e roles . ^ Complet e th e registratio n form(page s 7 an d8 ) an dth e notificatio n an ddescriptio n o f undergroun dstorag e tan k system s (page s 9 , 1 0 & 11 ) for all tank s bein g installe dat th e facility . > ^ Mak e copie s fo r

you r records . ^ Enclos e you r

chec k payabl e to : Orego n Departmen t

o f Environmenta l Quaht y ^ Retu mth e genera l pemii t registratio n for

m(page s 7 an d8) , th e notificatio n an d descriptio n o f

imdergroun dstorag e tan k system s (page s 9 , 1 0 & 11 ) an dth e correc t tota l fe e amoun t

to : DE Q Busines s Offic e 81 1 SW 6*''Avenu e Portland , Orego n 9720 4

Januar y 200 8 Pag e lo f 1 1 DEQ-05-LQ-016 A

## GENERA LINFORMATIO N PAG E

DESCRIPTIO N O FGENERA LPERMI T PROGRA M I n lie u o f issuin g individua l permits , Oregon' s US T permittin g progra mha s adopte dgenera l permit s b y rul e a s follows :

. Genera l Permi t

t o Instal l (OA R340-150-0160) : thi s rul e identifie s th e condition s an d requirement s tha t

cove r th e constructio n o f

an US T system . Genera l Perini t

t o Operat e (OA R340-150-0163) : thi s rul e identifie s th e condition s an d requirement s tha t

cover s th e operatio n o f

an US T syste mtha t

meet s th e performanc e standard s for

ne w o r upgrade dfacilities . Facilitie s registerin g fo r agenera l permi t

t o operat e are authorize dt o deposi t aregulate dsubstanc e suc ha s moto r fuel int o an UST . B y signin g th e registratio n forms , yo u ar e certifyin g tha t yo u wil l compl y withal l th e condition s an drequirement s ofth e genera l permit s t o instal l an doperate . Upo n receip t ofth e complete d registratio n forms , th e Departmen t wil l issu e aRegistratio n Certificat e t o Install . Thi s certificat e doe s no t authoriz e fue l delivery . T o receiv e aCertificat e t o Operat e authorizin g fuel delivery yo u mus t submi t t o you r DE Q regiona l offic e th e followin g documentation : 1 . US T Installatio n Checklist , 2 . Informatio n associate dwithth e equipmen t installe dincludin g alis t o f majo r syste m components , third-part y evaluations , manufacturers ' checklists , photograph s an dfire authority sign-off

, i f available . Whe n yo u receiv e you r

Certificat e t o Operat e yo u mus t provid e th e Operatin g Certificat e Numbe r t o you r fuel distributo r

s o the y can delive r

produc t t o you r facility . 

## DEFINITION S Instal l - mean s th e physica l constructio n o f al l o r part o f a n undergroun dtank , includin g bu t no t limite dto , activitie s suc ha s excavating ; backfilling ; testing ; prope r placemen t

o f tank , piping , releas e detectio n devices , corrosio n protectio n systems , spil l an doverfil l device s an dan y associate dadministrativ e activitie s suc ha s notifications , recpr dkeepin g an drecor dsubmissions . Operat e - mean s depositin g aregulate dsubstanc e into , storin g aregulate dsubstanc e i n o r dispensin g aregulate dsubstanc e froma n undergroun dstorag e tan k an dsuc hothe r

activities , includin g bu t

no t limite dto , performin g releas e detection , maintainin g corrosio n control , preventin g spill s an doverfills , investigatin g an dconfirmin g suspecte dreleases , conductin g maintenance , modifications , replacemen t an drepair s o f

equipment , maintainin g financial responsibility an dsubmittin g record s o n th e US T an dundergroun dpiping' s performance . Owne r - mean s aperso n wh o currentl y own s a n US T o r owne da n US T durin g th e operationa l lif e ofth e tank . I f

registere dwithth e Secretary o f State , Corporation s Division , th e tan k owne r i s th e lega l busines s name . Permitte e - mean s th e owne r o r perso n designate db y th e owner, wh o i s i n contro l o r ha s responsibilit y for

dail y US T syste moperatio n an dmaintenance , financial responsibility an dUS T operato r trainin g requirement s unde r agenera l permi t

pursuan t t o OA R340-150-016 0 throug h 340-150-0168 . I f

registere dwithth e Secretary o f State , Corporation s Division , th e permitte e i s th e lega l busines s name . Th e permitte e i s maile dth e annua l complianc e fe e invoice . Property Owne r

- mean s th e lega l owne r ofth e rea l property o n whic han US T i s locate d(th e nam e tha t appear s o n th e County dee drecords) . Registratio n Certificat e - th e documen t th e Departmen t

issue s t o acknowledg e receip t o f a genera l permi t

registratio n form . Th e registratio n certificat e t o operat e authorize s delivery o f regulate dsubstances , includin g moto r fiiels . Th e registratio n certificate s t o install , decommissio n o r manag e asyste mi n temporat y closur e d o no t authoriz e produc t

deliveries . SI C Cod e - Standar dIndustria l Cod e (se e page s 5 & 6 ) Januar y 200 8 Pag e 2 o f 1 1 DEQ-05-LQ-016A ^



# 8

i

### # 

## INSTRUCTIO N PAG E

TANK S REQUIRIN GA GENERA LPERMI T REGISTRATIO N FOR M 1 . Al l undergroun dtanks , includin g emergenc y generato r tanks , containin g petroleu mproduct s o r liste d chemicals , whic har e no t exemp t (example s ar e gasoline , diesel , industria l solvents , pesticide s an d herbicides) . 2 . Tank s an dpipin g wit h10 % o r mor e o f thei r tota l volum e beneathth e ground . 3 . Farmo r

residentia l moto r

fuel undergroun dtank s large r tha n 1,100 gallon s in capacity . 4 . Tank s containin g regulate dsubstance s an dno t permanentl y decommissione dprio r t o Ma y 1 , 1988 . 

## EXEMP T TANK S (GENERA LPERMI T REGISTRATIO N NO T REQUIRED ) 1 . Far mo r

residentia l moto r

fue l tank s o f

1,100 gallo n capacity o r less . 2 . Heatitt g oi l tank s use dfo r hea t o n th e sam e propert y wher e th e tank s ar e located . 3 . Septi c Tanks . 4 . Pipelin e Facilities . 5 . Surfac e hnpoundments . 6 . StormWate r

or Wast e Wate r

Collectio n System s 7 . Flow-Throug hProces s Tanks . 8 . Liqui dTraps . 9 . Tank s tha t

ar e abov e th e surfac e ofth e floo r i n an undergroun darea . 

## GENERA LPERMI T REGISTRATIO N FOR M 1 . Pleas e fill i n th e name , addres s an dphon e numbe r ofth e facility , hiclud e th e Facility I D numbe r i f thi s for mi s bein g submitte dfor

a n existin g facility tha t

ha s previousl y registere dothe r tanks . 2 . Pleas e provid e th e SI C cod e for eac hfacility (Se e page s 5 an d6) . 3 . Fo r ne w tanks , aregistratio n fee o f $135.0 0 pe r

tank an da n installatio n fee o f

$40 0 pe r tan k are du e for th e cuiren t

year . Fo r

multi-chambere do r

multi-compartmen t

tank , th e registratio n fe e i s $135.0 0 an dth e installation fe e $40 0 for eac hchambe r

o r compartment . Pleas e fil l in th e numbe r o f ne w tank s o r compartment s in th e spac e provide di n th e genera l permi t registratio n fe e section . Multipl y thi s numbe r b y $53 5 t o calculat e th e tota l amoun t owed . 4 . Pleas e fill i ath e tan k owner' s lega l name , addres s an dphon e number . Th e legal nam e i s th e nam e o f th e tan k owne r a s file dwithth e Secretary o f State , Corporation s Division , i f applicable . Th e tan k owne r mus t sig n th e registratio n form . 5 . Th e tan k

owne r can nam e apermitte e for eac hfacility . Pleas e as k th e pennitte e i n charg e ofth e facility t o fil l i n thei r

lega l name , addres s an dphon e number . Th e lega l nam e i s th e nam e ofth e permitte e a s file dwit hth e Secretary o f State , Corporation s Division , i f applicable . Th e permitte e mus t sig n th e registratio n form . 6 . Pleas e fil l i n th e propert y owner' s name , addres s an dphon e number . Th e property owner' s nam e shoul db e th e nam e in th e county dee drecords . Th e property owne r mus t sig n th e registratio n form . 7 . Ther e mus t

b e thre e signature s for

eac hcomplete dregistratio n for m- th e tan k

owner , permitte e an d propert y owner . I FON EPERSO N FILL S AL LTHRE EROLES , THA T PERSO N MUS T SIG N THREETIMES . 8 . Complet e page s 9 , 1 0 an d11 , Notificatio n an dDescriptio n o f Undergroun dStorag e Tan k Systems . 

## LICENSE D SERVIC EPROVIDER S AN D SUPERVISOR S OR S 466.75 0 an dOA RChapte r 340 , Divisio n 160 require s tha t license dservic e provider s perfor mtank installatio n work . NOTE : A N OWNE RO RPERMITTE EMA Y PERFOR M US T SERVICE S ONL Y I FTHE Y HAV ETAKE N AN D PASSE D TH EAPPROPRIAT EUS T SUPERVISO R EXAMINATIO N OFFERE D B Y A NATIONA LTESTIN GSERVIC E(OA R340-150-0156) . Durin g certai n critica l phase s a s specifie di n th e rules , alicense dsuperviso r mus t b e presen t

o n site t o monito r

th e work . List s o f

hcense dservic e provider s an dsupervisor s ar e availabl e upo n reques t b y callin g (503 ) 229
- 665 2 o r toll-fre e i n Orego n 1-800-742-787 8 ( amessag e answerin g machine) . Januar y 200 8 Pag e 3 o f 1 1 DEQ-05-LQ-016 A

## INSTRUCTIO N PAG E

US T SYSTE M OPERATO RREQUIRE D Th e owne r

o r permitte e o f

eac hUS T facility issue dan operatin g certificat e tha t dispense s aregulate d substanc e fro ma n US T t o amoto r vehicl e o r

containe r

mus t emplo y traine dpersonne l wh o can properl y operat e an dmaintai n th e US T syste man dprovid e emergenc y respons e informatio n t o an y perso n that dispense s aregulate dsubstanc e fromth e US T system . Fo r mor e detail s o n implementin g thi s requiremen t

se e rul e OA R340-150-020 0 or g o t o http://www.deq.state.or.us/lq/training.htm#trauiuig . 

## HEL PWIT H THI S REGISTRATIO N FOR M I f yo u hav e an y question s abou t thi s regisfratio n form , pleas e phon e th e DE Q US T Progra ma t (503 ) 229
- 6652 . Yo u ca n als o phon e th e US T Program' s toll-fre e number , 1-800-742-7878 . Thi s i s amessag e answerin g machin e fo

r call s mad e withi aOregon . Undergroun dStorag e Tank Progra mstaf

f will retu m you r call s withi n 2 4 hours . Yo u can als o sen da n e-mai l t o tanks.info@deq.state.o r us . Our regiona l staf f are als o availabl e t o answe r question s regardin g th e genera l penni t progra man dthi s genera l permi t regisfratio n for

m(se e belo w fo

r telephon e numbers) . 

## COPIE S O FGENERA LPERMI T CONDITION S AN D REQUIREMENT S AM ) US T PROGRA M RULE S Copie s ofth e genera l permi t t o iastal l an doperat e condition s an drequirement s an dUS T Progra mrule s an d law s can b e obtaine dfrom: 1 . An y o f

th e DE Q office s liste dbelow , 2 . B y callin g th e US T HELPLIN Eat 1-800-742-7878 , 3 . Sen dan e-mai l t o tanks.info@.deq.state.or.u s o r 4 . Downloadin g fromth e US T hom e pag e at : 

### http://www.deq.state.or.us/Iq/tanks/ust/mdex.ht m ^

NORTHWES TREGIO N Clackamas , Clatsop , Columbia , Multnoma h Tillamoo k

& Washingto n Countie s

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

EASTER N REGIO N /

TH EDALLE S Phone : 541-298-725 5 NORTHWES T REGIO N / PORTLAN D

- Phone:503-229-526 3 WESTER N REGIO N /

COO S BA Y Phone : 541-269-272 1 WESTER N REGIO N /

EUGEN E Phone : 541-686-783 8 US T HELPLIN E(I N OREGON) : WESTER N REGIO N / SALE M Phone : 503-378-824 0

1-800-742-787 8 ^ .

Januar y 200 8 Pag e 4 o f 1 1 DEQ-05-LQ-016 A

## INDE X O FSELEC T STANDAR D INDUSTRIA LCODE S

STANDAR D INDUSTRIA L CODE S FO R UNDERGROUN D STORAG E TANK S h e Standar d Industria l Classificatio n (SIC ) Cod e wa s develope d b yth e Federa l 'Governmen t t o ai d i n gatherin g econonni cstatistic s an d t o hel p compar e informatio n fro m differen t govemmen t agencies . Th e Departmen t o f Environmenta l Qualit y(DEQ ) use s SI C code s t o analyz e undergroun d storag e tan k location s an d t o Identifyth e businesse s tha t ow n tanks .

• ' •

# SI C code s defin e industrie s accordin g t o thei reconomi cstnjcture . The yclassif ybusinesse s bythei rmai n activitie s an d othe rmeasure s o f economi cactivity . (Thes e SI C code s ar e NO T th e sam e a s thos e use d o n taxfornis . Pleas e refe rt o thi s lis t fo rth e correc t SI C code) . DE Q ha s detemnine d tha t thi s lis t o f SI C code s wil l describ e man yo f th e businesse s tha t hav e undergroun d storag e tank s i n Oregon . I f you rbusines s i s no t listed , th e complet e lis t o f SI C code s ca n b e foun d i n th e referenc e section o f you rloca l libraryi n th e "Standar d Industria l Classificatio n Manual ' fo r1987 . Pleas e us e th e 198 7 manua l sinc e i t list s th e con'ect , revise d SI C codes . Pleas e us e th e FOU R digi t cod e tha t describe s th e mai n activit yo f you rbusiness . Fin d th e correc t division , bein g carefu l whe n selectin g manufacturing , wholesal e o rretail . (Ther e ar e simila rcode s i n eac h o f thes e categories. ) The n fin d th e majo rgrou p tha t describe s you r business . Th e FOU/ ? digi t cod e shoul d b e liste d within tha t majo rgroup . Fo rassistance , pleas e contact th e US TComplianc e Section , (503 ) 229-6652 .

DIVISIO N A- AGRICULTURE , FORESTR Y& FISHIN G CROP S 011 1 Wheat-Cas h Grain s 013 9 Fiel d Crop s - Alfalfa , Clover , Gras s Seed , Hops 016 1 Vegetable s An d Melon s 017 2 Grape s 017 3 Tre e Nut s - Filberts , Walnut s 017 5 Deciduou s Tre e Fruit s - Apples , Apricots , Cherries , Peach , Pear , Plum , Prun e 018 1 Ornamenta l Floricultur e & Nurser yProduct s 018 2 Foo d Crop s Grow n Unde rCove r- Bea n Sprouts , Greenhouses , Mushroom s 019 1 Genera l Fami s - Crop s LIVESTOC K 021 1 Bee fCattl e - Feedlot s 121 2 Bee fCattle , Excep t Feedlot s i21 3 Hog s 121 4 Shee p & Goat s 121 9 Genera l Livestock , Excep t Dair y& Poultry 024 1 , Dair

yFarm s 025 1 Broiler , Frye r& Roaste rChicken s 025 2 Chicke n Egg s 025 3 Turi<ey

s 8 , Turke yEgg s 025 4 Poult yHatcherie s 027 9 Anima l Specialtie s - Othe r(Be e Farms , Ca t Farms , Do g Farms , Hone yProduction ) 029 1 Genera l Famn s - Livestoc k AGRICULTURA L SERVICE S 071 1 Soi l Preparatio n - Fertilizing , Plowin g 072 1 Cro p Planting , Cultivatio n & Protectin g 072 2 Cro p Harvestin g - Machin e FORESTR Y 081 1 Timbe rTract s - Christma s Trees , Tre e Farm s 083 1 Fores t Nurserie s 085 1 Fores t Service s 092 1 Fis h Hatcherie s DIVISIO N B - MININ G MININ G & QUARRYIN G . 142 9 Crushe d & Broke n Ston e 144 2 Constructio n San d & Grave l DIVISIO N C - CONSTRUCTIO N BUILDIN G CONSTRUCTIO N 152 1 Genera l Contractor s - Singl e Famil yHouse s 152 2 Gen . Contractor s - Residentia l 153 1 Operativ e Builder s 154 1 Gen . Contractor s - Industria l Building s & Warehouse s 154 2 Gen . Contractor s - Nonresidentia l Building s HEAV YCONSTRUCTION-NO TBUILDING S 161 1 Highwa y& Stree t Constructio n 162 2 Bridge , Tunnel s & Elevate d Highway s 162 3 Water , Sewer , Pipelin e 8 i Communication s & Powe rUn e Constructio n SPECIA L TRAD E CONTRACTOR S 71 1 Plumbing , Heatin g & Ai rConditionin g 172 1 Paintin g & Pape rHangin g 173 1 Electrica l Wori t 174 1 Masonr

y& Stonewori ( 174 2 Plastering , Drywal l & Insulatio n Wor k 174 3 Tile , Martji e & Mosai cWori < 175 1 Carpentr

yWor k 175 2 Floors , Othe r 176 1 Roofing , Sidin g & Shee t Meta l 177 1 Concret e Wor k 178 1 Wate rWel l Drillin g 179 1 Structura l Stee l Erectio n " ^ 179 3 Glas s 8 i Glazin g 179 4 Excavafo n Wor k 179 5 Wreckin g & Demolitio n 179 6 Installatio n O rErectio n Of Buildin g Equipment , Othe r 179 9 Specia l Trad e Contractors , Othe r(Awnin g Installation , Dewaterin g Contractors , Hous e

Moving , Steeplejack s & Weathe rStripping )

DIVISIO N D - MANUFACTURIN G FOO D PRODUCT S 202 1 Creamer

yButte r 202 2 Chees e 202 4 Ic e Crea m 202 6 Mil k 203 2 Canne d Specialtie s 203 3 Canne d Emits , Vegetable s & Preserve s 203 4 Drie d Fruits , Vegetable s 8 i Soup s 203 5 Pickle d Fruit s & Vegetable s 203 7 Froze n Fmit s & Vegetable s 204 1 Flou r& Othe rGrai n Mil l Product s 204 7 Do g & Cat Foo d 205 1 Brea d & Baker

y 208 2 Mal t Beverage s 208 4 Wines , Brand y& Brand ySpirit s 208 5 Distille d & Blende d Liquors 208 6 Soft Drinks LUMBE R & WOO D PRODUCT S 241 1 Loggin g 242 1 Sawmill s & Planin g Mill s 242 6 Hardwoo d Dimensio n & Floorin g Mill s 243 1 Millwori ( 243 4 Woo d Kitche n Cabinet s 243 5 Hardwoo d Venee r& Plywoo d 243 5 Softwoo d Venee r& Plywoo d 244 8 Woo d Pallet s & Skid s 245 2 Prefabricate d Woo d Building s 249 1 Woo d Preservin g PAPE R SALLIE D PRODUCT S 261 1 Pul p Mill s 262 1 Pape rMill s 263 1 . Paperboar d Mill s 265 3 Corrugate d Boxe s 265 6 Sanitar

yFoo d Container s 267 3 Plastic , Foi l & Coate d Pape rBag s 267 4 Uncoate d Pape rBag s PRINTING , PUBLISHING , S ALLIE D INDUSTRIE S 271 1 Newspaper s 272 1 Periodical s 273 1 Books 273 2 Boo k

Printin g 275 2 Commercia l Printin g - Lithographi c 275 4 Commercia l Printin g - Gravur e 276 1 Manifol d Busines s Form s 278 9 Bookbindin g 279 1 Typesettin g CHEMICAL S S ALLIE D PRODUCT S 281 2 Alkalie s & Chlorin e 281 3 Industria l Gase s 281 6 Inorgani cPigment s 281 9 Industria l Inorgani cChemicals , Othe r 282 1 Plastic s 282 2 Syntheti cRubbe r 283 3 Medicina l Chemical s & Botanica l Product s 283 4 Phannaceutica l Preparation s 284 1 Soa p & Othe rDetergent s 284 2 Cleaning , Polishin g & Sanitatio n Preparation s 285 1 ' Paints , Vamishes , Lacquer s -286 9 Industria l Organi cChemical s 287 3 Nitrogenou s Fertilizer s 287 4 Phosphati cFertilizer s 287 9 Pesticide s Januar y 200 8 Pag e 5 o f 1 1 DEQ-05-LQ-016 A

## INDEX O FSELEC T STANDAR D INDUSTRIA LCODE S 289 3 Printin g In k PETROLEU M REFININ G S REL ATE D INDUSTRIE S 291 1 Petroleu m Refinin g 295 1 Asphal t Pavin g Mixture s RUBBER S MISCELLANEOU S PLASTIC S 301 1 Tire s ' 308 4 Plastic s Pip e 308 5 . Plastic s Bottle s PRIMAR YMETA L INDUSTRIE S 331 2 Steelwork s 332 1 . Gray& Ductil e Iro n Foundrie s 333 4 Primar

yProductio n O f Aluminu m 334 1 Secondar

ySmeltin g & Refinin g - Nonfen-ou s 336 5 Aluminu m Foundrie s 336 6 Coppe rFoundrie s DIVISIO N E -TRANSPORTATION , COMMUNICATIONS , ELECTRIC , GA S & SANITAR YSERVICE S RAILROA D TRANSPORTATIO N 401 1 Railroads , Line-Hau l Operatin g 401 3 Railroa d Switching/Terminal s LOCA L TRANSrr s HIGHW AYPASSENGE R TRANSPORT ATIO N 411 1 Loca l & Suburba n Transi t 412 1 Taxicab s 413 1 Intercity& Rura l Bu s Transportatio n 415 1 Schoo l Buse s 417 3 Tenriinai S Servic e Facilitie s MOTO R FREIGH TTRANSPORT ATIO N S WAREHOUSIN G 421 2 Loca l Tmckin g Withou t Storag e 421 3 Tmcking , No t Loca l 421 4 Loca l Tmckin g Wit h Storag e 421 5 Courie rService s 422 1 Far m Product Storag e 422 2 Refrigerate d Warehousin g & Storag e 422 5 Genera l Warehousin g & Storag e 423 1 Tennina l & Maintenanc e Facilitie s - Freigh t Transportatio n 431 1 . Unite d State s Posta l Servic e 449 3 Marina s TRANSPORTATIO N B YAI R 451 2 Ai rTransportatio n 451 3 Ai rCourie rService s 458 1 Airports , Flyin g Field s & Tenninal s COMMUNICATION S 481 2 Radiotelephon e 481 3 Telephon e 483 2 Radi o Broadcastin g Station s 483 3 Televisio n Broadcastin g Station s ELECTRIC , GA S S SANITAR YSERVICE S 491 1 Electri cService s 492 3 Natura l Ga s Distributio n 494 1 Wate rSuppl y 495 2 Sewerag e System s 495 3 Refus e System s 497 1 Irrigatio n System s DIVISIO N F -WHOLESALETRAD E DURABL E GOOD S 501 4 Tire s & Tube s 503 1 Lumber , Plywood , Millwori ( & Woo d Panel s 508 2 Constructio n & Minin g Equipmen t - Sol d T o Companie s 508 3 Fam i & Garde n Machiner y& Equipmen t - Sol d T o Farm s & Othe rBusinesse s 508 4 Industtia l Machinery& Equipmen t - Sol d T o Companie s 508 5 Industria l Supplie s 509 3 Scra p & Wast e Material s NONDURABL E GOOD S 514 1 Groceries , Genera l Lin e 514 2 Package d Froze n Food s •5143 Dair

yProduct s 514 4 Poultr

y& PoultryProduct s 514 6 Fis h & Seafoo d 514 7 Meat s & Mea t Product s 514 8 Fres h Fmit s & Vegetable s 517 1 Petroleu m Bul k Station s & Tenninal s 517 2 Petroleu m & Petroleu m Product s - No t Terminal s 518 1 Beer s Al

e 518 2 Win e & Distille d Alcoholi cBeverage s 519 1 Fan n Supplie s DIVISIO N G-RETAI L TRAD E BUILDIN G M ATERIAL S HARDWAR E GARDE N SUPP L YS MOBIL E HOM E DEALER S 521 1 Lumbe r& Othe rBuildin g Material s 525 1 Hardwar e Store s 526 1 Retai l Nurseries , Law n & Garde n Suppl yStore s 5271 - Mobil e Hom e Dealer s GENERA L MERCHANDIS E STORE S 531 1 Departmen t Store s 533 1 Variet yStore s FOO D STORE S 541 1 Grocer

yStore s 543 1 Emi t & Vegetabl e Mari(et s 545 1 Dair

yProduct s Store s AUTOMOTIC E DEALER S S GASOLIN E SERVIC E STATION S 551 1 Moto rVehicle s Dealers (Ne w& Used ) 552 1 Moto rVehicle s Dealers (Use d Only) 553 1 Aut o An d Hom e Suppl yStore s 554 1 Gasolin e Sen/ic e Station s 555 1 Recreationa l Vehicl e Dealer s 557 1 Motorcycl e Dealer s EATING S DRINKIN G PLACE S 581 2 Eatin g Place s 581 3 Drinkin g Place s (Alcoholi cBeverages ) 598 3 Fue l Oi l Dealer s

DIVISIO N H - FINANCE , INSURANC E & REA L ESTAT E DEPOSITOR YINSTITUTION S 602 1 Nationa l Commercia l Bank s 602 2 Stat e Commercia l Banks 602 9 Othe rCommercia l Banks 603 5 Saving s Institutions , Federall yChartere d 606 1 Credi t Union s REA L ESTAT E 651 2 Operator s O f Nonresidentia l Building s 651 3 Operators O f Apartmen t Building s 651 5 Operators O f Residentia l Mobil e Hom e Site s 653 1 Rea l Estat e Agent s & Manager s 655 2 Lan d Subdivider s & Developer s DIVISIO N I - SERVICE S HOTEL S ROOMIN G HOUSE S CAMP S S OTHE R LODGIN G PLACE S 701 1 Hotel s & Motel s - Includin g Recreatio n Facilitie s 703 2 Sportin g & Recreationa l Camp s 703 3 Recreationa l Vehicl e Parit s & Campsite s - Campground s 721 6 Drydeaner s AUTOMOTIV E REPAIR , SERVICE S S PARKIN G 751 3 Tmc k

Renta l & Leasin g 751 4 . Passenge rCa rRenta l 751 5 Passenge rCa rLeasin g 752 1 Automobil e Paridn g 753 2 Top , Bod y& Upholster yRepai rShop s 753 4 Tir e Retreadin g & Repai rShop s 753 7 Automotiv e Transmissio n Repai rShop s 753 8 Genera l Automotiv e Repai rShop s 754 2 Can«ashe s 754 9 Lubricatin g Servic e 8 i Othe rAutomotiv e Services , Excep t Repair/Carwashe s AMUSEMENT S RECRE ATIO N SERVICE S 799 2 Publi cGol f Course s 799 6 Amusemen t Parit s 799 9 Amusemen t & Recreatio n Services , Othe r- Pari<s , Fairgrounds , DayCamps ,

Rental , Sk i Lifts , Touris t Attraction s 806 2 Genera l Medica l & Surgica l Hospital s . 598 3 Fue l Oi l Dealer s EDUCATIONA L SERVICE S 821 1 Elementar

y& Secondar

ySchool s 822 1 Colleges , Universitie s & Professiona l School s 823 1 Librarie s 871 1 Engineerin g Service s

DIVISIO N J - PUBLI C ADMINISTRATIO N 911 1 Executiv e Offices—Office s Of Cities , Counties , Mayors , Etc . 912 1 Legislativ e Bodies—Cit yCouncils , Count yCommissioners , Etc . 919 9 Genera l Govemment—Othe rGovemmen t 922 1 Polic e ProtecBo n 922 3 Con-ectiona l Instihjtion s 922 4 - Fir e Protectio n 951 2 Land , Mineral , Wildlif e & Fores t Conservatio n 962 1 Regulatio n & Administratio n O f Transportation'Program s - Pot t Auttioritie s 

# n

Q

Mope d 

# i

Januar y 200 8 Pag e 6 of 1 1 DEQ-05-LQ-016 Astat e o f Otego n Departmerrt o f Environmenta l Quant y 

### OREGO N DEPARTMEN TO F ENVIRONMENTA L QUALIT Y

UNDERGROUN D STORAG E TAN KPROGRA M GENERA L PERMI TREGISTRATIO N FOR M



### AN D 30-DA YNOTIC E FO RDE Q US EONL Y Dat e Rec' d CkNo . Am t Rec' d$ Deposi t US T Permi t

Fee s

y j ] •..^ ; Le.Vi-- . vi--
- h'-^^r-.''
- : i i--::U J J_ i >>"U-. ; N j . N\i ^ 

# ! iffiil . AS S IHMtBIl

P

FACILIT Y NAME : FACILIT Y ADDRESS :
CITY , STATE& ZIP : PHONE : SI C CODE : FACILIT Y NUMBER : (I f known ) 

### GENERA LPERMI T REGISTRATIO N FE E

* 

### Fo r

ne w tanks , aregistratio n fe e o f $135.0 0 pe r

tan k an da n installation fee o f $40 0 pe r tan k i s du e for

th e curren t

year . Fo r

multi-chambere do r

multi-compartmen t

tanks , th e registratio n fe e i s $135.0 0 an dth e installatio n fe e i s $40 0 for eac hchambe r

o r compartment . T o calculat e th e registratio n fe e owe dpleas e fil l i n th e blank s below : Numbe r o f ne w tank s o r

compartment s X $535.0 0 0 Tota l Fe e Du e Thi s registratio n fe e wil l als o serv e a s th e fijst annua l complianc e fe e for th e remairdn g portio n ofth e year

i n whic hth e registratio n for mi s submitted . Januar y 200 8 Pag e 7 o f 1 1 DEQ-05-LQ-016i ^

# GENERA LPERMI T REGISTRATIO N FOR M



# T O INSTAL LAND OPERAT EUST s

1 . TAN K

OWNER * a s registere dwith th e Secretary o f

State , Corporation s Divisio n
Nam e o f Official (Pleas e Print ) Signatur e o f

Official Dat e Mailin g Addres s (Pleas e Print )

City , State an dZi p Cod e
Are aCod e an dTelephon e Numbe r I wil l instal l an doperat e th e UST s describe do n ih Q Notificatio n an dDescriptio n o f Undergroun dStorag e Tan k System s page s i n accordanc e wit hth e condition s an drequirement s ofth e applicabl e genera l pennits .

2 . PERMITTEE * a s registere dwithth e Secretary o f

State , Corporation s Divisio n
Nam e o f Official (Pleas e Print ) Signatur e o f

Official Dat e Mailin g Addres s (Pleas e Print )

City , State an dZi p Cod e
Are aCod e an dTelephon e Numbe r I wil l instal l an doperat e th e UST s describe do n th e Notificatio n an dDescriptio n o f Undergroun dStorag e Tan k System s page s i n accordanc e wit hth e condition s an drequirement s ofth e applicabl e general permits .


### 3 . PROPERT Y OWNE Ri s nam e tha t appear s o n th e County dee drecor dfor thi s property .
Nam e o f Official (Pleas e Print ) Signatur e o f

Official - - - Dat e Mailin g Addres s (Pleas e Print )

City , State an dZi p Cod e
Are aCod e an dTelephon e Numbe r * I f thi s facilit y o r tanks ar e owne db y aperson , o

r operate db y apermittee , tha

t i s abusines s registeredwit hthe Secretar y o f State , Corporation s Division , pleas e us e tha t lega l busines s nam

e fo r purpose s o

f registering thes e UST s wit hthe Department . Pleas e retur n complete dpage s 7 & 8 , th e Notification andDescriptio n o f Undergroun dStorag e Tank System s page s 9,1 0 an d11 , an dapplicabl e registratio n fe e to : DE Q - Busines s Offic e 81 1 S W6*

* Avenu e Portland , Orego n 9720 4 

# d

^

Januar y 200 8 Pag e 8 of 1 1 DEQ-05-LQ-016 A

### Notificatio n an d Descriptio n o f Undergroun d Storag e Tan k System s 

# 'f t TYP E O F OWNE R INDIA N COUNTR Y Federa l Governmen t I • I Stat e Governmen t I I Loca l Governmen t I I Commercia l I I Privat e Tank s ar e locate d o n lan d v\/ithl n a n India n I I Reservatio n o ro n trus t land s outsid e — reservatio n boundaries . Tank s ar e owne d b ya Nativ e America n natio n o rtribe . 

# B Trib e o rNation :

TYP E O F FACILIT Y I I Ga s Statio n I I Petroleu m Distributo r I I Ai rTax i (Airline ) I J Aircraf t Owne r J Aut o Dealershi p I I Railroa d I I Federa l - Non-Military I I Federa l - Military I J Industria l I I Contracto r I I Trucking/Transpor t n n utilitie s I I Residentia l 

### I I Far m I I Othe r(Explain ) FINANCIA L RESPONSIBILIT Y 

# • I wil l mee t th e financia l responsibilit yrequirement s i n accordanc e wit h OA R 34 0 - Divisio n 15 1 Chec k Al l tha t Appl y j . J Pollutio n Liabilit yInsuranc e ^ ^ ^ Sel f Insuranc e ^^F J Exemp t (Federa l o rStat e Government ) 

# L I I Lette ro f Credi t I I Suret yBon d I I Guarante e I ; : I Loca l Governmen t



### Th e financia l responsibilit yrequirement s ar e designe d t o mak e sur e tha t th e tan k owner , propert yowne ro r permitte e ca n pa yth e cost s o f cleanin g u p leak s an d compensatin g thir d partie s fo rbodil yinjuryan d propert ydamag e cause d b yleakin g USTs . Aplai n languag e summaryofth e financia l responsibilit y requirement s ca n b e downloade d fro m th e Interne t a t http://www.epa.gov/swerust1/pubs/dollars.htm . Fo ra lis t o f know n insuranc e provider s g o t o http://www.epa.gov/swerust1/pubs/inslist.htm . CONTAC TPERSO N I N CHARG E O F TANK S Name : Jo b Title : Address : Phon e Numbe r(includ e Area Code) :

CERTIFICATIO N (Rea d an d sig n afte rcompletin g al l section ) I certif yunde rpenalt yo f lawtha t I hav e personall yexamine d an d a m familia rwit h th e Informatio n submitte d i n thi s an d al l attache d documents , an d tha t base d o n m yinquiryo f thos e individual s immediatel yresponsibl e fo robtainin g th e infonnation , I believ e tha t th e submitte d informatio n i s true , accurate , an d complete . Nam e an d officia l titl e o f owne ro rowner' s authorize d representativ e (Print ) 

# k
Signatur e Dat e Signe d

Januar y 200 8 Pag e 9 o f 1 1 DEQ-05-LQ-016 ANOTIFICATIO N AN D DESCRIPTIO N O F UNDERGROUN D STORAG E TAN KSYSTEM S ^ (Complet e fo reac h tan k a t thi s location ) fi^ Tan k Identificatio n Numbe r Tan k No . Tan k

No . Tan k

No . Tan k

No . 

### TankNi ^ 1 . Statu s o f Tan k

(Chec k

(V ) onl yone ) Currentl yI n Us e Temporaril yOu t o f Us e Permanentl yOu t o f Us e 2 . Dat e o f Installatio n (mont h & year ) 3 . Estimate d Tota l capacit y(gallons ) 4 . Materia l o f constructio n (Chec k (V ) al l Asphal t Coate d o rBar e Stee l CathodicaU yProtecte d Stee l

Epox yCoate d Stee l Composit e (Stee l wit h Fiberglass ) Fiberglas s Reinforce d Plasti c

Line d Interio r Doubl e Walle d Polyethylen e Tan k

Jacke t Concret e Excavatio n Line r Unknow n Othe rMaterial , Pleas e Specif y Ha s Tan k

bee n Repaired ? Chec k (V ) Bo xi f Ye s Dat e o f Repai r \ \ \ • Iil l 

# 1 1 1 1

1 - lliii i 

# 1 1 1 1

L

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# 1 1 1 1

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# 1 1 tha t apply ) 1 1 1 iHli k 

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# 1 1 1 liiii i 

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## ( g ^ 

# 1 9
5 . Pipin g - Materia l (Chec k (V ) al l tha t apply ) Bar e Stee l Bar e Stee l Wrappe d Galvanize d Stee l Fiberglas s Reinforce d Plasti c Coppe r CathodicaU yProtecte d

Doubl e Walle d Secondar ycontainmen t

Unknow n No t i n Contac t Wit h Soi l Othe rMaterial , Pleas e Specif y 6 . Pipin g - Typ e (Chec k (V ) al l tha t appl y Suctio n - n o valv e a t tan k Suctio n - valv e a t tan k

Pressur e Gravit yFee d Ha s Pipin g bee n Repaired ? Chec k (V ) bo xi f Ye s Dat e o f Repai r 

# 1 1

iiii l | o t 

# 1 1 iiii l . -.jlii i



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## \ 1 iiiii l • liiiiiiii i 

# 1 1 iiiiiiiii l \s m 1 • 1 1 liiiiiiiii N 1 • • liiiii i L • liiiiii i :;;i:i:;ii:iilii : , j-;|:;i|::;: -

1 iiiiiiiii'ii i iiii i iiii l |:;a::|i ;

liiMiii ; Iiiiiiiii l J
ii i iiiiiiiii l _ | 

### ' 

# I I iWii l .:.:•: ! 

# 1 1 •ii| - - I 

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# I I

iiiii l :

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# 1 1 iiiiiiliiii j • : , ' I liiiliiiiliiii l • • - 1 1 1 

# 1 1

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iiiiiiiii l • . • 1 

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# 1 1 / / _ ^ 

# ^-J t

Januar y 200 8 Pag e 1 0 o f 1 1 DEQ-05-LQ-016 A

# i NOTIFICATIO N AN D DESCRIPTIO N O F UNDERGROUN D STORAG E TAN KSYSTEM S (Complet e fo reac h tan k a t thi s location ) Tan k Identificatio n Numbe r Tan k No . Tan k

No . Tan k

No . Tan k

No . Tan k

No . 7 . Substanc e Currentl yo rLas t Store d i n Greates t Quantit yb yVolum e (Chec k (V ) Onl yOn e Substanc e Pe rTank )

Gasolin e [ [ Diese l ] Gasoho l Kerosen e Heatin g Oi l Use d Oi l Hazardou s Substanc e CERCLANam e and/o r

CAS Numbe r Mixtur e of Substance s Pleas e SpecifyMixtur e

Othe r Pleas e SpecifyOthe r 8 . Releas e Detectio n (Chec k (V ) al l tha t Appl y Manua l Tan k

Gaugin g Tan k Tightness;Testing i Inventor yContro l Automati cTahkiiGiEigihgl i Vapo rMonitorin g Groundwate rMonitorin g Secondar

yContainmen t [ Automati cLin e Lea k

Detecto r Lin e tightnes s Testin g N o Releas e Detectio n Require d (Emergenc yGenerato r/ / Fiel d Constructe d Tanks ) 

### Othe rMetho d Allowe d by

Departmen t Othe rMethod , Pleas e Specify 9 . Spil l an d Overfil l Protectio n Overfil l Devic e Installe d Spil l Devic e Installe d

Januar y 200 8 Pag e 1 1 o f 1 1 DEQ-05-LQ-016 A

# ^^o ^ DE Q Stat e of Orego n Departmen t o f Environmenta l Qualit y 

# CERTIFICAT ET O OPERAT E

UNDERGROUND , STORAG ETANK S REGISTRATION CERTIFICAT ENUMBER : 24-7752-2008:-OPER . FACILIT Y NAM EAND LOCATIO N SALE M MOTO RPOO L, • 110 0 AIRPOR T R D S E' , -/1' , ; : SALEM , O R97301-608 2 TAN K PERMI T BCHH J BCHJ K BCHJ A BCHJ B 

# TAN K I D N O l A 3 A 4 A 5 A 

# TAN K SIZ E 20,00 0 Gallon s ^20,00 0 Gallon s 1,00 0 Gallon s 60 0 Gallon s 

# PERMITTE E

Richar dMaxwel l Orego n Dep t

o f Administrativ e Service s 110 0 Airport

RdS E Salem , O R97301-608 2 TAN K CONTENT S Gasolin e Diese l MOTO ROIL Use dOi l 

# CERTIFICAT EEXPIRES : Jun e 30 , 200 9 ISSU EDATE : 06/05/200 8 (3Uvx<feif^ ^ 

## Andre e Pollock , US T Progra mManage r Lan dQuality Divisio n Pos t thi s certificat e wher e i t i s visibl e t o th e perso n deliverin g fuel .- ^ ^

^

Slat e o f Orego n 

## Th e Orego n Departmen t ofEnvironmenta l Quality issue s thi s annual operatin g certificat e withth e understandin g tha t th e permitte e wil l operat e i n accordanc e wit

hth e condition s andrequirement s ofth e general De^^rtm ^ permi t t o operat e a

n undergroun dstorag e tan k (UST ) pursuant

t o OA R E^on^n. , 340.150-0163 . Postin g o f

th e annua l operatin g certificate : Th e permitte e mus t

pos t th e annual operatin g certificat e i n aconspicuou s locatio n a t th e US T facility clearl y visibl e t o thos e depositin g regulate dsubstance s into th e UST . Th e permitte e shall , upon request , presen t i t t o aDepartmen t

o f Environmental Quality representative . Th e operatin g certificat e i s weather
resistant . Th e annua l operatin g certificat e wil l automaticall y terminate : • 6 0 day s after

achang e i

n ownershi p ofth e property , achang e i n tan k ownershi p or

achang e i

n th e designate dpermittee ; • Upo n issuanc e o f

atemporary closur e certificat e o r when temporary closure , change-in-servic e or permanen t

closur e begins ; • On th e expiratio n date . T o repor t

change s i n designate dpermittee , tan k ownership , propert y ownershi p o r use s ofth e tan k o r t o obtai n copie s o f

th e Orego n law s an drule s tha t appl y t o th e operatio n o f USTs : • Cal l 503-229-665 2 o r leav e amessag e a

t 1-800-742-787 8 (toll-fre e i n Oregon ) • Fa x t o 503-229-697 7 • E-mai l t o tanks.info@deq.state.or.u s • Mai l to : Orego n Departmen t o f Environmenta l Quality Undergroun dStorag e Tan k Program 81 1 S W6t

hAvenu e Portland , O

R9720 4 • Fo r copie s o f laws , rule s or

form s g o t o th e US T Progra mWeb sit e at : http://www;deq.state.or.us/lq/tanks/ust/index.htm Suspecte dan dactua l release s fro mUST s mus t b e reporte dt o DE Q withi n 2 4 hour s b y contacting : • Northwes t

Regio n - Portlan dOffic e (Clackamas , Clatsop , Columbia , Multnomah , Tillamoo k an d Washington ) http://www.deq.state.or.us/nwr/offices.htm • Western Regio n - SalemOffic e (Benton , Lane , Lincoln , Linn , Marion , Pol k an dYamhill ) http://www.deq.state.or.us/wr/ol'fices.htm • Wester

n Regio n - Coo s Ba

y Offic e (Coos , Curry , Douglas , Jackso n an dJosephine ) http://www.deq.state.or.us/wr/offices.htm • Easter

n Regio n (Baker , Crook , Deschutes , Gilliam , Grant , Harney , Hoo dRiver , Jefferson , Klamath , Lake , Malheur , Morrow , Sherman , Umatilla , Union , Wallowa , Wasc o an dWheeler ) http://www.deq.state.or.us/er/olTices.htm • Orego n Emergenc y Managemen t Division' s Orego n Emergenc y Respons e Syste m(OERS ) a t 1
- 800-452-031 1 if

aDE Q Regional Offic e canno t b e reache danda

n emergenc y conditio n exists
b e specifi c that

i t involve s aspil l or

releas e fromundergroun dstorag e tanks . ! • •

f \ YOU R TAN K ' li
JIV . TODAY ? »*»»( »

# DE Q Stat e of Otego n Depdrtmen t o f Environmenta l Qualit y 

## OREGO N DEPARTMEN TO F ENVIRONMENTA L QUALIT Y UNDERGROUN D STORAG E TAN KPROGRA M GENERA L PERMI T

## REGISTRATIO N FOR M 

## t o DECOMMISSIO N EXISTIN G UNREGISTERE D TANK S an d 

## 30-DA Y NOTIC E 

## O F INTEN TTO DECOMMISSIO N USTS

Thi s for mfor registratio n o f

existin g tank s tha t

hav e neve r

bee n reporte dt o DE Q shoul db e submitte dat

leas t 30-day s befor e beginnin g decommissionin g b y permanen t

closure . T o registe r

existin g tank s yo u mus t

submi t page s 4 throug h8 o f

thi s registratio n for

m an dachec k

for th e amoun t

ofth e require dregistratio n fee . Se e pag e 4 t o calculat e th e require dfee . ^ . I f yo u ar e registerin g mor e tha n fiv e (5 ) tanks , pleas e mak e acop y o f page s 7 an d8 . Lis t th e additional tank s o n th e copy . Yo u mus t cal l you r regiona l offic e t o receiv e authorizatio n t o procee dwithth e decommissionin g at

leas t 7 2 hour s prio r

t o begirmin g work . Se e pag e 3 for phon e numbers . Yo u mus t submi t th e Undergroun dStorag e Tan k Decommissionin g Checklis t an d Sit e Assessmen t

Repor t t o you r loca l Regiona l Offic e withi n 3 0 day s followin g completio n ofth e tan k

decommissionin g o r

change-in-servic e regardles s i f cleanu p wor k i s ongoing .
CHECKLIS T 1 . B e sur e signature s ar e provide dfor th e tan k owner , permitte e an dproperty owner , eve n wher e on e perso n fills al l thre e roles . 2 . Complet e th e registratio n for mfor al l tank s bein g registere da t th e facility . 3 . Mak e copies fo r

you r records . 4 . Enclos e you r

chec k payabl e to : Orego n Departmen t

ofEnvironmenta l Quality 5 . Pleas e rettt mth e genera l permi t registratio n for

man dapplicabl e registratio n fe e to : Departmen t

ofEnvironmenta l Quality Busines s Offic e 81 1 S WSixthAvenu e Portland , Orego n 9720 4

Octobe r200 8 Pag e 1 o f 8 08-LQ-09 9

## INSTRUCTIO N PAG E

DESCRIPTIO N OFGENERALPERMI T PROGRA M I n lie u o f issuin g individua l permits , Oregon' s US T permittin g progra mha s adopte dagenera l permi t b y rul e t o decommissio n UST s tha t identifie s th e condition s an drequirement s fo r temporary an dpermanent . closur e o r completin g achange-in-service . B y signin g th e registratio n forms , yo u are certifyin g that yo u wil l compl y withal l th e condition s an drequirement s ofth e genera l permi t t o decommissio n USTs . 

## DEFINITION S Facility - th e plac e wher e th e tank i s located . Decommissio n - means temporary o r permanen t

closure , includin g temporary o r permaiien t

remova l from operation , filling in-place , remova l fromth e groun do r change-in-servic e t o non-regulate dstatus . Owne r - means aperso n wh o currentl y own s an US T o r owne dan US T durin g th e tank s operationa l life . I f registere dwithth e Secretary o f State , Corporation s Division , th e US T owne r i s th e legal busines s name . Permitte e - means th e owne r o r perso n designate db y th e owner , wh o i s in contro l o r ha s responsibility fo r dail y US T syste moperatio n an dmaintenance , financial responsibility an dUS T operato r trainin g requirement s unde r

agenera l permi t

pursuan t t o OA R340-150-016 0 throug h340-150-0168 . If registere d withth e Secretary o f

State , Corporation s Division , th e permitte e i s th e lega l busines s name . Th e permitte e i s maile dth e aimual complianc e fee invoice . Property owne r

- mean s th e legal owne r ofth e rea l property o n whic han US T i s locate d(th e nam e tha t appear s o n th e County dee drecords) . 

## GENERALPERMI T REGISTRATIO N FOR M 1 . Pleas e fill i n th e name , addres s an dphon e numbe r ofth e facility . I f

thi s facilit

y i s registere dwithDE Q pleas e includ e th e DE Q facilit y number . 2 . Pleas e fill in th e numbe r o f tank s in th e spac e provide di n th e genera l permi t

registratio n fee section . Fo r existin g tank s no t

previousl y registered , bac k fee s ar e require db y OA R340-150-011 0 (6) . Calculat e th e tota l amoun t due . 3 . Pleas e fill i n th e tan k owner' s lega l name , addres s an dphon e number . Th e legal nam e i s th e nam e o f th e tank owne r a s filedwithth e Secretary o f State , Corporation s Division , i f applicable . Th e tank owne r mus t sig n th e regisfratio n form . 4 . Th e tank

owne r can designat e apermitte e for eac hfacility . Pleas e as k th e permitte e i n charg e ofth e facility t o fill in thei r

legal name , addres s an dphon e number . Th e legal nam e i s th e nam e ofth e permitte e a s filedwithth e Secretary o f State , Corporation s Division , i f applicable . Th e permitte e mus t sig n th e registratio n form . 5 . Pleas e fill in th e property owner' s name , addres s an dphon e number . Th e property owner' s nam e shoul db e th e nam e in th e county dee drecords . Th e property owne r mus t sig n th e regisfratio n form . 6 . Ther e mus t

b e thre e signature s for

eac hcomplete dregisfratio n for m- th e tarik

owner , permitte e an d property owner . I FON EPERSO N FILL S AL LTHRE EROLES , THA T PERSO N MUS T SIG N THREETIMES . 7 . Complet e al l section s an dpage s ofth e form . 

## LICENSE D SERVIC EPROVIDER S AN D SUPJERVISORS OR S 466.75 0 an dOA R34 0 - Divisio n 160 require s tha t license dservic e provider s performtan k decommissio n work . I f

contaminate dsoi l i s discovere ddurin g decommissioning , an dadecisio n i s mad e t o remediat e th e site usin g th e soi l mafri x rules , OR S 466.75 0 an dOA R34 0 - Divisio n 162 require s tha t license dservic e provider s performsoi l matri x cleanu p work . Durin g certai n critica l phase s a s specifie din th e rules , alicense dsuperviso r mus t b e presen t

o n sit e t o monito r

th e work . A lis t

o f Hcense dservic e provider s an dsupervisor s i s availabl e upo n reques t b y callin g (503 ) 229-665 2 o r toll-fre e i n Orego n 1-800
- 742-787 8 ( amessag e answerin g machine) . NOTE : A N OWNE RO RPERMITTE EMA Y PERFOR M US T SERVICE S ONL Y I FTHE Y HAV ETAKE N AN D PASSE D TH EAPPROPRIAT EUS T SUPERVISO REXAMINATIO N OFFERE D B Y A NATIONA LTESTIN GSERVIC E(OA R340
- 150-0156) . Octobe r200 8 Pag e 2 o f 8 08-LQ-09 9

## INSTRUCTION PAGE

HEL PWIT H Tin s REGISTRATIO N FOR M I f yo u hav e any question s abou t thi s regisfratio n form , pleas e phon e th e DE Q US T Programa t (503 ) 229
- 6652 . Yo u can als o phon e th e US T Program' s toll-fre e Orego n number , 1-800-742-7878 . Thi s i s a messag e answerin g machin e for call s mad e in Oregon . Undergroun dStorag e Tan k Programstaf

f will retu myou r

cal l withi n 24hour s (on e busines s day) . Yo u can als o sen da n e-mai l t o tanks.info@deq.state.or.us . Ou r regiona l staf

f i s als o availabl e t o answe r question s regardin g th e genera l permi t

progra man dthi s genera l permi t regisfratio n for

m(se e belo w fo

r telephon e numbers) . 

### COPIE S O FGENERA LPERMI T CONDITION S AN D REQUIREMENT S AN D US T PROGRA M RULE S

• \• ' • • . Copie s ofth e genera l permi t t o decommissio n condition s an drequirement s an dUS T Programrule s an d law s can b e obtaine dfrom: f ' • . ' • 1 . An y o f

th e DE Q office s Hstedbelow , 2 . B y callin g th e US T HELPLIN Eat 1-800-742-7878 , 3 . Sen d an e-mai l t o tanks.info@deq.state.or.us
. o r 4 . Dovvnloadin g fromth e US T hom e pag e at : 

### http://www.deq.state.or.us/lq/tanks/ust/index.ht m Vie w Orego n Adminisfrativ e Rule s (OAR ) an dope n Divisio n 15 0 t o OA R34-150-016 6 & 340-150-0168 . Vie w Orego n Revise dStatute s (ORS ) an dope n Chapte r 46 6 t o OR S 466.70 6 t o 466.84 5

NORTHWES TREGIO N Clackamas , Clatsop , Columbia , Multnomah , Tillamoo k

& Wastiingto n Countie s

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

EASTER N REGION/THEDALLE S Phone : 541-298-725 5 NORTHWES T REGIO N Phone : 503-229-526 3 US T HELPLINE : 1-800-742-787 8 (tol l free in Oregon ) WESTER N REGIO N / SALE M Phone:503-378-824 0 WESTER N REGIO N /

COO S BA Y Phone : 541-269-2721 WESTER N REGIO N /

EUGEN E Phone:541-686-783 8

Octobe r200 8 Pag e 3 o f 8 08-LQ-09 9

# GENERA LPERMIT REGISTRATION FOR M 

# T O DECOMMISSIO N UNREGISTERE D UST s

IMLFSA^If , IHMKf f

FACILIT Y NAME : FACILIT Y ADDRESS :

CITY , STATE& ZIP : PHONE : ^ FACILIT Y NUMBER : ^___^^ ^

(If known) GENERA LPERMI T REGISTRATIO N FE E Fo r existin g tank s installe di n 198 8 o r earlie r th e registratio n fe e i s $50 0 pe r tank . Numbe r o f existin g tank s bein g registere d__ ^ x $50 0 = $ Tota l Fe e Du e Note : I f a n existin g tan k

was installe dafte

r 198 8 pleas e contac t

th e Departmen t

at 503
- 229-665 2 o r

1 -800-742-787 8 for

assistanc e i n calculatin g th e fee . Fo r existin g tank s no t

previousl y registere dan dpermitted , bac k fee s are du e an dpayabl e withthi s genera l permi t

registratio n for

mi n accordanc e withOA R340-150-011 0 (6) . 30-DA Y NOTIC EO FINTEN T T O DECOMMISSIO N INFORMATIO N Wor k T o B e Performe dBy : ''-
- •-. - '• • •''-•
- ' ' ' ' ' ' • ' ' .. . (Nam e o f Permittee , Tan k

Owner , Property Owne r

or License dServic e Provider ) 

### I f performe db y Servic e Provider : Licens e #' • ••••':•• ' • •'-• • Contac t Phone : Contac t Mobile Phone : i Wil l tan k remova l o r

potentia l cleanu p affec t

adjacen t property o r

right-of-way property ? Ye s N o Dat e decommissionin g i s schedule dt o begin :

Octobe r200 8 , Pag e 4 o f 8 08-LQ-09 9y 

# GENERA LPERMIT REGISTRATION FOR M 

# T O DECOMMISSIO N UNREGISTERE D UST s

1 . TAN K

OWNER'* ^ a s registere dwith th e Secretary o f

State , Corporations-Divisio n
Nam e o f Official (Pleas e Print ) Signatur e o f

Official , Dat e Mailin g Addres s (Pleas e Print )

City , State an dZi p Cod e
Are aCod e an dTelephon e Nimibe r I wil l decommissio n th e UST s describe do n th e Notificatio n an dDescriptio n o f Undergroun dStorag e Tank System s page s in accordanc e withth e condition s an drequirement s ofth e genera l permi t t o decommission .

2 . PERMITTEE * a s registere dwithth e Secretary o f

State , Corporation s Divisio n
Nam e o f Official (Pleas e Print ) Signatur e o f

Official Dat e . • • ' •: . • / ^- ^ : : : •• • ' . ' • • • ' Mailin g Addres s (Pleas e Print )

City , Stat e an dZi p Cod e
Are aCod e an dTelephon e Numbe r I wil l decommissio n th e UST s describe do n th e Notificatio n an dDescriptio n o f Undergroun dStorag e Tan k System s page s in accordanc e withth e condition s an drequirement s ofth e genera l permi t t o decommission . 

### 3 . PROPERT Y OWNE Ri s nam e tha t appear s o n th e County dee drecor dfor thi s property .
Nam e o f Official (Pleas e Print ) Signatur e o f

Official Dat e Mailin g Addres s (Pleas e Print )

City , State an dZi p Cod e
Are aCod e an dTelephon e Numbe r ' * I f thi s facilit y o r tanks ar e owne db y aperson , o

r operatedb y apermittee tha

t i s abusines s registeredwit

hth e Secretar y o f State , Corporation s Division , yo u must us e tha t lega l busines s nam

e fo r purpose s o

f registering thes e USTs wit hthe Department . Pleas e mak e sur e tha t you r busines s registration wit

hthe Orego

n Corporation s Divisio

n (503
- 986-2200) i s active o

r you r application ma

y be placedo

n hol duntil you r registration has bee

n renewed . Return Complete dFor

mto : Departmen

t ofEnvironmenta

l Qualit y Busines s Offic

e 8t l S WSixt hAvenu e Portland , O

R9720 4 . Octobe r200 8 Pag e 5 o f 8 08-LQ-09 9"\ . 

### Notificatio n an d Descriptio n o f Undergroun d Storag e Tani cSystem s TYP E O F OWNE R INDIA N COUNTR Y Federa l Governmen t | j Commercia l Stat e Govemmen t | | Privat e [ J Loca l Governmen t 

# a Tank s ar e locate d o n lan d withi n a n India n Reservatio n o ro n trus t land s outsid e reservatio n boundaries . Tank s ar e owne d b ya Nativ e America n natio n o rtribe . 

# • Trib e o rNation :

TYP E O F FACILIT Y [ J Ga s Statio n I . I Petroleu m Distributo r I I Ai rTax i (Airiine ) I [Aircraf t Owne r I [Aut o Dealershi p Railroa d Federa l - Non-Military Federa l - Military Industria l Contracto r Trucking/Transpor t Utilitie s Residentia l Far m Othe r(Explain ) . : FINANCIA L RESPONSIBILIT Y I 11-wil l mee t th e financia l responsibilit yrequirement s i n accordanc e wit h OA R 34 0 - Divisio n 15 1 Chec k Al l tha t Appl y I J Pollutio n Liabilit yInsuranc e [ I Sel f Insuranc e I I Exemp t (Federa l o rStat e Governmen t I I Lette ro f Credi t [ J Suret yBon d I I Guarante e 1 I Loca l Govemmen t



### Th e financia l responsibilit yrequirement s ar e designe d t o mak e sur e tha t th e tan k owner , propert yowne ro r permitte e ca n pa yth e cost s o f cleanin g u p leak s an d compensatin g thir d partie s fo rbodil yinjuryan d propert ydamag e cause d b yleakin g USTs . Aplai n languag e summaryofth e financia l responsibilit y requirement s ca n b e downloade d fro m th e Interne t a t http://www.epa.gov/swerust1/pubs/dollars.htm . Fo ra lis t o f know n insuranc e provider s g o t o http://www.epa.gov/swerust1/pubs/inslist.htm . CONTAC TPERSO N I N CHARG E O F TANK S Name ; Jo b Title : Address : Phon e Numbe r(Includ e Are a Code) :

CERTIFICATIO N (Rea d an d sig n afte rcompletin g al l section ) I certif yunde rpenalt yo f la wtha t I hav e personall yexamine d an d a m familia rwit h th e informatio n submitte d i n thi s an d all attache d documents , an d tha t base d o n m yinquir

yo f thos e individual s Immediatel yresponsibl e fo robtainin g th e information , I believ e tha t th e submitte d infonnatio n i s true , accurate , an d complete . Nam e an d officia l titl e o f owne ro rowner' s authorize d representativ e (Print ) 

## Title : ::mMZ^mz^-zmmmM

m Signatur e Dat e Signe d



### Octobe r200 8 Pag e 6 of 8 08-LQ-09 9

### NOTIFICATIO N AN D DESCRIPTIO N O F UNDERGROUN D STORAG E TAN KSYSTEM S ^ ^ (Complet e fo reac h tan k a t thi s location ) ^ R k Identificatio n Numbe r Tan k No . Tan k

No . Tan k

No . Tan k

No . 

### Tan k

No . 1 . Statu s o f Tan k

(Chec k (V ) onl yone ) Currentl yi n Us e Temporaril yOu t o f Us e Permanentl yOu t o f Us e 2 . Dat e o f Installatio n (mont h & year ) 3 . Estimate d Tota l Capacit y(gallons ) 

## 1 1 1 l l 

## 1 1 i l

1 : : 1 

### L1

1 1 

# 1 1 1 . 1



# 1 - - 11 • 1

1 1 1 1 4 . Materia l o f Constructio n (Chec k (V ) al l tha t apply ) Asphal t Coate d o rBar e Stee l CathodicaU yProtecte d Stee l Epox yCoate d Stee l Composit e (Stee l wit h Fiberglass ) Fiberglas s Reinforce d Plasti c

Line d Interio r Doubl e Walle d Polyethylen e Tan k

Jacke t Concret e Excavatio n Line r Unknow n ^ ^ Othe rMaterial , PleiseiSfecif y ^ ^ Ha s Tan k

bee n Repaired ? Chec k rV) Bo xi f Ye s Dat e o f Repair s ' 

## 1 1 

# 1 : 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 i l 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 . Pipin g - Materia l (Chec k (V ) ai l tha t appl y Bar e Stee l Bar e Stee l Wrappe d Galvanize d Stee l Fiberglas s Reinforce d Plasti c Coppe r

. CathodicaU yProtecte d

Doubl e Walle d Secondar yContainmen t

Unknow n No t i n Contac t wit h Sdil l Othe rMaterial , Pleas e Specif y 

## 1 1 1 : l . l i 

## 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 . Pipin g - Typ e (Chec k (V) al l tha t apply ) Suctio n - N o Valv e a t Tan k Suctio n - Valv e a t Tan k

Pressur e Gravit yFee d Ha s Pipin g bee n Repaired ? 9 Chec k N ) Bo xi f Ye s Dat e o f Repai r 

## 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

Octobe r200 8 Pag e 7 o f 8 08-LQ-09 9

### NOTIFICATIO N AN D DESCRIPTIO N O F UNDERGROUN D STORAG E TAN KSYSTEM S ^ ^Complet e fo reac h tan k at thi s location ) '^ ^ Tan k Identificatio n Numbe r Tan k No . Tan k

No . Tan k

No . Tan k

No . Tan k

No . 7 . Substanc e Currentl yo rLas t Store d i n Greates t Quantit yb yVojum e Chec k (^l ) Ohi vOn e Substanc e De rTank ) Gasolin e Diese l Gasoho l Kerosen e Heatin g Oi l Use d Oi l 1 1

1 1 1 1 1 1 1 1 1 \ 

### 1 1



## 1 r 1 1 \ 1 

### 1 1 i i « ! • 1 :


### Hazardou s Substanc e CERCLANarmSaMb B

CA S Numbe r 1 1 

### 1 1

• : .- . • :.^ - "• • • 

### 1 1 

## I I 1 1 1 • . . . ' . '


### Mixtur e o f Substance s Pleas e SpecifyMixtur e 1 i 

### 1 1 1 1 1 1 1 1
^ 

### Othe r Pleas e SpecifyOthe r 1 1 

### 1 1 1 1 • , . ' 

### 1 1 1 - ^ 

### 8 . Releas e Detectio n (Chec k (V ) al l tha t Appl y Manua l Tan k

Gaugin g Tan k Tightnes s Testin g Inventor yContro l Automati cTan k

Gaugin g Vapo rMonitorin g Groundwate rMonitorin g Secondar

yContainmen t Automati cLin e Lea k

Detecto r Lin e Tightnes s Testin g N o Releas e Detectio n Require d (Emergenc

yGenerato r/

/ Fiel d Constructe d Tanks ) Othe rMetho d Allowe d byDepalmen t Othe rMethod , Pleas e Specify Tan k 1 1 

### 1 1 1 1 1 1 1 1 1 Is 1 1 

# B

1 1 1 1 

### Pip e 1 Tan k

| Pip e | Tan k

| Pip e | Tan k

| Pip e | Tan k

| Pip e 

# m
1 1 

### 1 1 1 1 1 1 1 l l 1 1 

### 1 1 1 1 

### 1 1 1 1 ^ 1 1 1 l i 1 1 1 I f 1 1 

# • • ^^ 1 1 1 1 1 

# •
\ \ 1 1 f l 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 

# ^n m 1 l i 

## 1 1 ::L_J l 1 i I I f 

### 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 j f 

### 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 I f 1 1 1 1 i i 

# 1 9 . Spil l an d Overfil l Protectio n

Overfil l Devic e Installe d Spil l Devic e Installe d 1 1 1 1 • 1^-----^ ^

- 1 1 1 

### I - - - 1 1 1 ^ ^
Octobe r200 8 Pag e 8 o f 8 08-LQ-09 9

### - < ^ 

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

### OREGO N DEPARTMEN TO F ENVIRONMENTA L QUALIT Y

UNDERGROUN D STORAG E TAN KPROGRA M

GENERA L PERMI TREGISTRATIO N FOR M FO RDE Q US EONL Y Dat e Rec' d CkNo . Am t Rec' d$ US T Pemii t

. . - ' fc* • • . #• - / . * 

### Thi s for mi s t o b e use dwhe n ther e i s achang e o f tan k owner , permitte e o r

property owner . Thi s for mmus t b e retume dwithi n 120 day s o f achang e i n tan k

owner , permitte e o r

property owne r

s o that arevise dGenera l Permi t Certificat e t o Operat e ca n b e issue dt o insur e th e facilit y ca n continu e t o legall y receiv e produc t deliverie s suc ha s moto r fiiel . A $7 5 permi t

modificatio n fee mus t

accompan y thi s form . Before DE Q ca n issu e ane w Genera l Permi t Certificat e t o Operate , yo u mus t submi t proo f o f complianc e wit hth e financial responsibilit y rules . Acceptabl e mechanism s for demonstratin g complianc e wit hpollutio n liability requirement s ar e foun di n OA RChapte r 34 0 - Division 15 1 an d describe di n th e publicatio n Dollar s an dSense . T o obtai n acop y o f Dollar s an dSens e cal l 503
- 229-665 2 o r

downloa di t

fro mth e Inteme t

at http://www.epa.gov/swerustl/pubs/dollars.htm . FACILIT Y NAME : FACILIT Y ADDRESS :
CITY , STAT E& ZIP : 

### ^ Cl F

DAT EOWNER/PERMITTE EINFORMATIO N CHANGED : PHONE : SI C CODE : 

### FACILIT Y NUMBER :

1 . 2 . 3 . 4 . REMINDE R B e sur e signature s ar e provide dfo r tan k owner , permitte e an dproperl y owner , eve n wher e on e perso n fills al l thre e roles . Mak e copie s fo r

you r records . Includ e achec k

o r mone y orde r

fo r $7 5 payabl e t o DEQ . Pleas e retu mth e genera l permi t modificatio n form , financial responsibility verificatio n document s (i.e . Certificat e o f Insurance , Lette r

fro mChie f

Financia l Officer , etc. ) an dfe e to : DE Q Busines s Offic e 81 1 S W6* " Avenu e Portland , Orego n 9720 4 Augus t 200 7 Pag e 1 of 3 DEQ-0S-LQ-018 A

## INSTRUCTIO N PAG E US T SYSTE M OPERATO RREQUIRE D Th e owne r

o r permitte e ofeae hUS T facility issue dan operatin g certificat e tha t dispense s aregulate dsubstanc e fro ma n US T t o amoto r

vehicl e o r

containe r

mus t emplo y traine dpersonne l wh o can properl y operat e an dmamtai n th e US T syste man dprovid e emergenc y respons e informatio n t o an y perso n tha t dispense s aregulate dsubstanc e fromth e US T system . Fo r

mor e detail s o n unplementin g thi s requiremen t see rul e OA R340-150-020 0 o r g o t o http://www.deq.state.or.us/lq/training.htm#Trai n ing . . - 

## HEL PWIT H THI S PERMI T MODIFICATIO N FOR M I f yo u hav e any question s abou t thi s permi t

modificatio n form , pleas e phon e th e DE Q US T Programat (503 ) 229-6652 . Yo u can als o phon e th e US T Program' s toll-fre e number , 1-800-742-7878 . Thi s i s amessag e answerin g machin e for call s mad e withi n Oregon . Undergroun dStorag e Tan k Programstaf

f will retu myou r

call s withi n 2 4 hours . Yo u can als o sen dan e mai l t o tanks.info@deq.state.or.us . Ou r regiona l staf

f ar e als o availabl e t o answe r question s regardin g th e genera l permi t ^ progra man dthi s permi t

modificatio n for

m(se e belo w for

telephon e numbers) . 

## COPIE S O FGENERA LPERMI T CONDITION S AN D REQUIREMENT S AN D US T PROGRA M RULE S , Copie s ofth e genera l permi t t o operat e condition s an drequirement s an dUS T Programrule s an dlaw s can b e obtaine dfrom: 1 . An y o f

th e DE Q office s liste dbelow , 2 . B y callin g th e US T HELPLIN Eat 1-800-742-7878 , 3 . tanks.info(5),deq.state.or.us , o r 4 . Downloadin g fromth e US T hom e pag e at : 

### http://www.deq.state.or.us/lq/tanks/ust/index.ht m NORTHWES TREGIO N Clackamas , Clatsop , Columbia , Multnomah , Tillamoo k & Washington Countie s
WESTER N REGION : Benton , Coos , Curry , Douglas , Jackson , Josephine , Polk , Lane , Lincoln , Linn , Mario n & Yamhil l Countie s EASTER N REGION : Baker , Crook , Deschutes , Gilliam , Grant , Harney , Hoo d River , Jefferson , Klamath , Lake , Malheur , Mon'ow , Shemnan , Umatilla , Union , Wasco , Wheeler & Wallow a Countie s

EASTERN REGION/TH EDALLE S Phone:(541)298-725 5 NORTHWES T REGIO N Phone:(503)229-526 3 US T HELPLIN E(I N OREGON ) 1-800-742-787 8 WESTER N REGIO N / COO S BA Y Phone : (541 ) 269-2721 , Ext . 3 1 WESTERN REGIO N /

EUGEN E Phone : (541 ) 686-783 8 WESTER N REGIO N /

SALE M Phone : (503 ) 378-824 0 V , '

Augus t 200 7 Pag e 2 of 3 DEQ-05-LQ-018 A

## T O MODIF Y OWNERSHI PO RPERMITTE EINFORMATIO N GENERA L PERMI TREGISTRATIO N FOR M 

# T O OPERAT EUST s

1 . TAN K

OWNER * a s registere dwithth e Secretary o f

State , Corporation s Divisio n
Nam e o f Official (Pleas e Print ) Signatur e o f

Official Dat e Mailin g Addres s (Pleas e Print )

City , State an dZi p Cod e

••.•••'../ ' Are aCod e an dTelephon e Numbe r I wil l operat e th e previousl y registere dUST s maccordanc e withth e condition s an drequirement s ofth e genera l permi t pursuan t t o OA R340-150-0163 .

2 . PERMITTEE * a s registere dwithth e Secretary o f State , Corporation s Divisio n
Nam e o f Official (Pleas e Print ) Signatur e o f

Official Dat e ^ 1 Mailin g Addres s (Pleas e Print )

City , State an dZi p Cod e
Are aCod e an dTelephon e Numbe r I wil l operat e th e previousl y registere dUST s in accordanc e wit hth e condition s an drequirement s ofth e genera l permi t pursuan t t o OA R340-150-0163 .

3 . PROPERT Y OWNE Ri s nam e tha t appear s o n th e County dee drecor dfp r thi s property .
Nam e o f Official (Pleas e Print ) Signatur e o f

Official Dat e Mailin g Addres s (Pleas e Print )

City , State an dZi p Cod e
Are aCod e an dTelephon e Numbe r * I f thi s facilit

y o r tank s are owne dby aperson , o r operate db y apermittee, that i s abusines s registere dwit hth e Secretar

y o f State , Corporation s Division , pleas e us e that legal busines s nam e fo

r purpose s o f

registerin g thes e UST s withth e Department . 

### I f yo u hav e an yquestions , pleas e contac t th e DE Q US TProgra m at : 1-800-742-787 8 (toll-fre e i n Oregon ) o r1-503-229-665 2 (out-of-state ) Fa xNumbe r503-229-697 7
Augus t 200 7 Pag e 3 of 3 DEQ-05-LQ-018 A

### ^ ^ ^



### ^ 

# DE Q Stat e of Orsgo n Departmen t o f Enviio n menta l Qualit y 

# OREGO N DEPARTMEN TO F ENVIRONMENTA L QUALIT Y

UNDERGROUN D STORAG E TAN KPROGRA M 

# GENERA L PERMI TREGISTRATIO N FOR M RETUR N T O SERVIC E APPLICATIO N u--r-.T'TiL^'"^'•li'"''vr!'^"" ' ••iT'"'"~T'"r\ ' ix'^^ir^:\'''^c^^vi- h%'^\'~^t^' • '\.n^ . Us e thi s formt o obtai n an operatin g certificat e for a n US T no w i n temporary closur e o r whose . previou s operatin g certificat e was suspende do r revoked . Thi s for

mmus t b e submitte ds o that

a Genera l Permi t

Certificat e t o Operat e ca n b e re-issue dt o insur e th e facihty ca n legall y receiv e produc t deliverie s suc ha s moto r fiiel . Before DE Q ca n issu e aGenera l Permi t Certificat e t o Operate , yo u mus t submi t proo f o f complianc e wit hth e financial responsibilit y rules . Acceptabl e mechanism s for demonstratin g complianc e wit hpollutio n liability requirement s are foun di n OA RChapte r 34 0 - Divisio n 15 1 an d describe di n th e publicatio n Dollar s an dSense . T o obtai n acop y o i Dollar s an dSens e cal l 503
- 229-665 2 o r

downloa di t

fro mth e Inteme t

at http://v^rvvw.epa.gov/swerustl/pubs/dollars.htm . Upo n receip t

o f a n application , US T Inspector s wil l b e notifie dan dgive n achanc e t o evaluat e th e operatin g condition s ofth e USTs . Whe n th e facilit y i s deeme din^complianc e technicall y an d administratively , an operatin g certificat e tha t allow s fue l deliverie s wil l b e issued . FACILIT Y NAME : FACILIT Y ADDRESS :
CITY , STAT E& ZIP : FACILIT Y CONTAC T NAME : FACILIT Y PHONE : 

### FACILIT Y NUMBER :

2 . 3 . 

### REMINDER S B e sur e signature s ar

e providedfo

r tan k owner , permittee an

dpropert y owner , eve

n wher e on e perso n fills al l thre e roles . Mak e copie s fo r you r records . If an y annua l complianc e fee s ar

e due , an y civil penaltie s have not

bee n paid , o r ther e has bee n a chang e i n permittee , tan

k owne r o r propert y owner, pleas e contact

DE Q a t 503-229-665 2 fo

r furthe r instructions . A

n annua l operating certificat

e will no t b e issueduntil all fee s ar

e paid . Pleas e retumthi s application for man dproof of financia l responsibilit

y (i.e . Certificat

e of Insurance , Lette

r fromChief

Financia l Officer, etc. ) to : DE Q Tan k Progra m 81 1 S W6 * Avenu e Portland , Orego n 9720 4 

## J

Octobe r 2008 Page 1 o f 4 08-LQ-10 6

## REGULATE D SUBSTANC EINFORMATIO N T O RETUR N T O SERVIC E HEL PWIT H BRINGIN GTH EUS T SYSTE M BAC K I N OPERATIO N DEQ , recommend s tha

t yo u retu mapreviousl

y closedUST syste

mto servic e wit

hthe assistanc e o

f alicensedUST Service Provider . Electronic equipmen

t ma y nee dcalibration an

dseal s ma y dr y ou t i n US T systems tha

t have bee n inactive fo

r ayea r o r more . B y employin g the service s o

f a nUST Service Provider, operationa l problems ca

n be avoide

do r correctedquickl

y befor e mor e seriou s problems develop , including preventing significan t spill s o r release s fro

mfault y seal s o r improperl y operating lea

k detectio n equipment . \ 

## US T SYSTE M OPERATO RREQUIRE D Th e owne r

o r permitte e ofeae hUS T facility issue dan operatin g certificate tha t dispense s aregulate dsubstanc e fro ma n US T t o amoto r

vehicl e o r

containe r

mus t emplo y traine dpersonne l wh o can properl y operat e an dmaintai n th e US T syste man dprovid e emergenc y respons e informatio n t o any perso n that dispense s aregulate dsubstanc e fromth e US T system . Fo r

mor e detail s o n implementin g thi s requiremen t se e rul e OA R340-150-020 0 o r g o t o http://vyww.deq.state.o r

.us/lq/training.htm#Training . 

## HEL PWIT H THI S FOR M I f yo u hav e any question s abou t thi s retu mt o servic e applicatio n form , pleas e phon e th e DE Q US T Programa t (503 ) 229
- 6652 . Yo u can als o phon e th e US T Program' s toll-fre e number , 1-800-742-7878 . Thi s i s amessag e answerin g machin e for call s mad e withi n Oregbn . Undergroun dStorag e Tank Progra mstaf

f wil l retu myou r

call s withi n 2 4 hours . Yo u can als o sen dan e-mai l t o tanks.info(a),deq.state.or.us . Ou r regiona l staf

f can als o answe r

question s regardin g th e genera l permi t programan dthi s retu mt o servic e applicatio n for m(se e belo w for

telephon e numbers) . 

## COPIE S O FGENERA LPERMI T CONDITION S AN D REQUIREMENT S AN D US T PROGRA M RULE S CA N B EOBTAEVE D FROM : 1 . An y ofth e DE Q office s liste dbelow , 2 . B y callin g th e US T HELPLIN Eat 1-800-742-7878 , 3 . tanks.info@,deq.state.or.us , o r 4 . Downloadin g fromth e US T hom e pag e at : 

### http://www.deq.state.or.us/lq/tanks/ust/index.ht m NORTHWES TREGION : Clackamas , Clatsop , Columbia , Multnomah , Tillamoo k & Washingto n Countie s
WESTER N REGION : Benton , Coos , Curry , Douglas , Jackson , Josephine , Polk , Lane , Lincoln , Linn , Mario n & Yamhil l Countie s EASTER N REGION : Baker , Crook , Deschutes , Gilliam , Grant , Harney , Hoo d River , Jefferson , Klamath , Lake , Malheur , Morrow , Sherman , Umatilla , Union , Wasco , Wheele r & Wallow a Countie s

EASTER N REGION/THEDALLE S Phone:(541)298-725 5 NORTHWES T REGIO N Phone : (503 ) 229-526 3 US T HELPLIN E(I N OREGO N lc800-742-787 8 WESTER N REGIO N / COO S BA Y Phone : (541 ) 269-2721 , Ext . 3 1 WESTER N REGIO N /

EUGEN E Phone : (541 ) 686-783 8 WESTER N REGIO N /

SALE M Phone : (503 ) 378-824 0 Octobe r 200 8 -Pag e 2 o f 4 08-LQ-10 6

## REGULATE D SUBSTANC EINFORMATIO N T O RETUR N T O SERVIC E GENERA L PERMI TREGISTRATIO N FOR M 

# T O OPERAT EUST s

1 . TAN K

OWNER * a s registere dwit hth e Secretary o f

State , Corporation s Divisio n
Nam e o f Official (PteasePn/i ^ Signatur e o f

Official Dat e Mailin g Addres s (Pleas e Print )

City , State an dZi p Cod e
Are aCod e an dTelephon e Numbe r I wil l operat e th e previousl y registere dUST s in accordanc e withth e condition s an drequirement s ofth e genera l permi t pursuan t t o OA R340-150-0163 .

2 . PERMITTEE * a s registere dwithth e Secretary o f State , Corporation s Divisio n
Nam e o f Official (Pleas e Print ) Signatur e o f

Officia l Dat e Mailin g Addres s (Pleas e Print )

City , State an dZi p Cod e
Are aCod e an dTelephon e Numbe r I wil l operat e th e previousl y registere dUST s in accordanc e withth e condition s an drequirement s ofth e genera l permi t pursuan t t o OA R340-150-0163 .
3 . PROPERT Y OWNE Ri s nam e tha t appear s o n th e County dee drecor dfor thi s property . 'Name o f Official (Pleas e Print ) Signatur e o f

Official Dat e • ' • ' ••/• : , • • . • • . • . : .-J
- Mailin g Addres s (Pleas e Print )

City , State an dZi p Cod e
Are aCod e an dTelephon e Numbe r * I f thi s facilit y o r tank s ar e owne db y aperson , o

r operatedb

y apermittee , tha

t i s abusines s registeredwit

hthe Secretar

y o f State , Corporation s Division , pleas e use tha t lega l busines s nam

e fo r purpose s o

f registering thes e UST s wit

hth e Department . 

### I f yo u hav e an yquestions , pleas e contac t th e DE Q US TProgra m at : 1 -800-742-787 8 (toll-fre e I n Oregon ) o r1 -503-229-665 2 (out-of-state ) Fa xNumbe r503-229-6977
Octobe r 200 8 Pag e 3 o f 4 08-LQ-10 6

## REGULATE D SUBSTANC EINFORMATIO N T O RETUR N T O SERVIC E

Fo r th e purpose s o f

fillin g i n th e tabl e below , an y moto r fuel containin g u p t o 10 % ethano l shal l b e considere dgasolin e an dreporte do n th e "gasoline " line . An y gasolin e containin g mor e than 10 % ethano l shal l b e considere da n "other " fuel an dreporte do n th e "other " line . O n th e "pleas e specif y other " lin e pleas e indicat e th e ethano l conten t ofth e fiiel suc ha s 85 % o r E85 . Fo r th e purpose s o f

fillin g i n th e tabl e below , an y moto r fuel containin g an y quantity o f biodiese l (i . e . 10 % o r BIO , 20 % o r

B20 , 99 % o r

B99 ) shal l b e considere dan "other " fue l an dreporte do n th e "other " line . O n th e "pleas e specif y other " lin e pleas e indicat e th e biodiese l conten t ofth e fuel suc ha s 20 % o r B20 . I f yo u ar e dispensin g a

n altemat e fuel that

i s 100% ) o r

B100 , tha t

i s not considere daregulate d substanc e at

thi s tim e an dth e US T doe s no t requir e aDE Q operatin g certificat e at thi s time . Finally , "gasohol " i s an antiquate dter man dDE Q woul dnot expec t tan k owner s t o us e thi s line . However , thi s ter mremain s o n th e federa l reportin g for ms o DE Q ha s lef

l i t o n th e stat e for

munti l suc h tim e a s th e Environmenta l Protectio n Agenc y update s th e nationa l reportin g program . NOTIFICATIO N AN D DESCRIPTIO N O F UNDERGROUN D STORAG E TAN KSYSTEM S (Complet e fo reac h tan k a t thi s location ) Tan k Identificatio n Numbe r Tan k No . Tan k

No . Tan k

No . Tan k

No . Tan k

No . 7 . Substanc e Currentl yo rLas t Store d i n Greates t Quantit yb yVolum e (Chec k (V ) Onl yOn e Substanc e Pe rTank )

Gasolin e Diese l Gasoho l Kerosen e Heatin g Oi l Use d Oi l Hazardou s Substanc e ; rK CA S Numbe r |;:; | - • • 1.; ; 

### : 1 1 1 1^ ^ 

## 1 - 1 1 1 1 1 ? l • . . j : 

### 1 1 1 1 

## 1 : : 1 1 1 i l ". ; i 

### 1 1 \ - ; : •• ,; • "; • • :f i 

## 1 1

:-••/ : • • • • • •:: i 

### 1 1

Mixtur e o f Substance s Pleas e Specif yMixtur e 

## 1 1 

# 1 1 1 1 

## 1 1 1 1

Othe r Pleas e Specif yOthe r 1 : 1 

# I I 1 : : : . :: | |.,.::•::.:. . .,.., | 

## 1 - -^--- 1

Octobe r 200 8 Pag e 4 of 4 08-LQ-10 6