# r 11 1 41 ] 

## OREGO N DEPIARTMENT O FENVIRONMENTA LQUALIT Y UNDERGROUN D STORAG E TAN K PROGRA M 30-DA Y NOTIC E O FINTEN T T O DECOMMISSIO N UST S O RCOMPLET E A CHANGE-IN-SERVIC E 1 . FACILIT Y (Locatio n o f Tanks ) {Pleas e Print ) Name : Address : 

### 2 . FERMITIE E (PleasePrint ) Name : Address : ••<:::!:v?;;;v:.:;;- ^ V. \%::':-'•-".'- r • • •;-^ : •.- . •^•:'.-:• : Phone : Phone : DE Q Genera l Permi t

Operatin g Certificat e Number : Work T o B e Performe dBy : • (Permittee , Tan k

Owner , Propert y Owne r o r Licens e Phone : Mobil e Phone : Licens e # dServic e Provider ) (Servic e Provider )

- '



## ^9D . THI S FOR M MUS T B E SUBMITTE D B Y US T PERMITTE E3 0 DAY S BEFOR ESTAR T O FWOR K

YO U MUS T CONTAC T YOU RLOCA LDE Q REGIONA LOFFIC E3-DAY S BEFOR ESTARTIN GAN Y

DECOMMISSIONIN GWORK . (Phon e number s are liste do n Pag e 2) N o 

### IJVill tan k remova l o r

potentia l cleanu p affec t

adjacen t propert y o r

Right-of-Wa y property ? Ye s at e decommissionin g i s schedule dt o begin : "-•. . -: • • •• •

TAN K ID # DEQ-US T

PERMI T # TAN K SIZ E IN GALLON S PRODUCT : GASOLINE ,

DIESEL , USE D OIL , OTHER ? PRESEN T NE W CLOSUR E O RCHANGE-IN

- SERVICE ? TAN K REMOVA L 

# n CLOSUR E

I N PLACED CHANG E

I N SERVICE * TAN K T O B E REPLACED ? YES * N O

* If decommissione dtank(s ) ar e t o b e replace db y ne w imdergroun dstorag e tank s yo u mus t submi t aGenera l Permi t Registratio n For mt o Instal l an dOperat e UST s fo r th e ne w tank s 3 0 day s befor e installin g them . • Submi t

asoi l sampling pla n t o th e DE Q regiona l offic e an dreceiv e plan approva l prio r t o startin g wor

k i f (1 ) tank i s t o b e decommissione din-place , (2 ) tan k content s ar e change dt o a n unregulate dsubstanc e o r (3 ) tan k contain s aregulate d substanc e othe r

tha n petroleum .

« Permittee : W:WW:::M M Permittee : Ss; : ::;;:;:;:;: ; SisBSSS:;:: ; Wm mffiSSS (Pleas e Print ) (Signature ) Date : 1 (

Augus t 200 7 Pag e lo f 2 DEQ-05-LQ-020 ATHI S NOTIC E AN D TH E 3-DA Y TELEPHON E NOTIC E AR EREQUIRE D prio r t o startin g decommissionin g wor k o n a regulate dundergroun dstorag e tan k (UST) . Decommissionin g work include s bu t

i s no t limite dt o excavatio n an dremova l ofth e tan k an dit s appurtenances , removafo f undergroun dpipin g (product , ven t an dvapo r

recovery piping) , soi l sampling , an dgroundwate r sampling . (Decommissionin g UST s o r completin g achange-in-servic e mus t b e don e i n accordanc e withth e condition s an d requirement s o f

OA R340-150-0166 , th e genera l permi t t o decommissio n USTs) . THI S NOTIC E I S NO T REQUIRE D fo r decommissionin g unregulate dtanks . T o determin e whethe r an undergroun dtank

i s regulate dpleas e refe r

t o OA R340-150-000 8 for UST' s tha t

ar e exclude do r

deferte dfromregulation , an dOA R340-150-001 0 (82 ) for th e defmitio n o f

aUST , o r

contac t DEQ . (Example s ar e heatin g oil , an dmos t residentia l or

far mmoto r fue l tank s unde r

110 0 gallons. ) AL LPAS T DU E US T GENERA LPERMI T ANNUA LCOMPLIANC EFEE S MUS T B EPAI D befor e thi s decommissionin g notic e wil l b e accepte db y DEQ . MAK E SUR E THI S FOR M I S COMPLET E WIT H AL LATTACHMENT S a s anotic e that i s incomplet e wil l no t

b e accepted . 

# RETUR N COMPLETE D AN D SIGNE D FOR M T O TH E DE Q REGIONA L

OFFIC E FO RYOU RARE A (Addresse s ar e liste dbelow) . 3-DA Y NOTICE : Contac t you r loca l DE Q Regiona l Offic e 3-day s befor e startin g work . (Phon e number s ar e liste dbelow) . NORTHWES T REGIO N 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

EASTERN REGIO N /

TH E DALLE S 400 E . Sceni c Drive , Buildin g 2 - 30 7 Th e Dalles , O R9705 8 Phone : 541-298-725 5 Fax : 541-298-733 0 NORTHWES T REGIO N 202 0 S W4thAvenue , Suite 400 Portland , O R97201-588 4 Phone : 503-229-526 3 Fax : 503-229-694 5 WESTER N REGIO N / COO S BA Y 38 1 N SECON D STREE T COO S BA Y 9742 0 Phone : 541-269-272 1 Fax:541-269-798 4 WESTER N REGIO N /

EUGEN E 110 2 Lincol n Street , Suite 210 Eugene , O R9740 1 Phone : 541-686-783 8 Fax : 541-686-755 1 WESTER N REGIO N / SALE M 75 0 Fron t Stree t NE , Suite 12 0 Salem , O R97301-103 9 Phone : 503-378-824 0 Fax : 503-373-794 4



## Fo r informatio n o r

assistanc e withthi s for

mcal l (503 ) 229-665 2 o r

th e US T HELPLINE : 1-800-742-787 8 (Tol l Fre e i n Oregon) . Progra minformation , registratio n forms , administrativ e rules

- an d othe r publication s can als o b e foun don ou r Homepag e at : http://www.deq.state.or.us/lq/tanks/ust/index.hti n Augus t 200 7 Pag e 2 o f 2 DEQ-05-LQ-020 A

## •^c ^ 

# DE Q stat e o f Ons^x i DepsftiKien t o f Envltanmeiita l 

## OREGO N DEPARTMEN T O F ENVIRONMENTA L QUALIT Y UNDERGROUN D STORAG E TAN KPROGRA M UNDERGROUN D STORAG E TAN KDECOMMISSIONIN G CHECKLIS TAN D SIT E ASSESSMEN T REPOR T

A . FACILIT Y INFORMATION : Thi s repor t

MUS T b e submitte db y th e undergroun dstorag e tari k permitte e o r

tan k owner , o r

th e license dDE Q Servic e Provide r

o n thei r behalf , withi n 3 0 day s followin g completio n o f th e tan k

decommissionin g o r change-in-servic e regardles s o f ongoin g cleanu p work . . DEO FACILIT Y NUMBER : FACILIT Y NAME : FACILIT Y ADDRESS : PERMITTE E PHONE : 1 DATE : 

### |B . WOR K

PERFORME D BY : Th e checklis t

an dsit e assessmen t

report shoul db e complete dan dsigne db y th e DE Q license dsuperviso r an dsigne db y a

n executiv e officer

ofth e DE Q license dServic e Provide r o n pag e 6 . Th e tan k

owne r o r permitte e mus t

revie w an dsig n th e report o n pag e 6 . NOTE : A N OWNE RO RPERMITTE E MA Y PERFOR M US T SERVICE S ONL Y I FTHE Y HAV E TAKE N AN D PASSE D TH E APPROPRIAT E US T SUPERVISO REXAMINATIO N OFFEREDB Y A NATIONA LTESTIN GSERVIC E (SE E OA R340-150-015 6 fo r requirements) . DE Q Service Provider' s Licens e # : Construction Contractors Boar dLicens e # : 

# 1 Name : Telephone : DE Q Decommissioning Supervisor' s Licens e # : Name : Telephone : DE Q Soil Matri

x Servic e Provider' s Licens e # :

Name : ; Telephone : DE Q Soil Matri

x Supervisor' s Licens e # :

Name : : Telephone : \ (I f applicable)

(If applicable)

Augus t 2007 Pag e 1 o f 7 DEQ-08-LQ-07 3C . DATES :

Note : servi c conta i Decommissioning/Chahge-in-Servic e Notic e - Dat e Submitted : Wor k Start Telephon e Notic e - Numbe r issue db y DEQ : DE O Perso n Notified : Dat e Wor k Started : • Dat e Wor k Completed : (3 0 day s befor e work starts) . J



# i ( 3 workin g day s befor e work starts) . V .

Provid e th e followin g informatio n i f an y soi l o r

wate r contaminatio n i s foun ddurin g th e decommissionin g o r change-in

e . Contaminatio n mus t

b e reporte db y th e US T permitte e withi n 2 4 hours . Th e license dservic e provide r mus t report tninatio n withi n 7 2 hour s afte r discovery unles s previousl y reported . Dat e Contaminatio n Reported : By : , DEO Perso n Notified :

D . OTHE RDE Q PERMIT S MA Y B E NEEDE D WHER E SOI LO RWATE RCLEANU PI S REQUIRED . DEO Wate r

Discharg e Permi t

# : Wate r Dispose dt o (Location) : DEO Soli dWast e Disposa l Permi t # : Soi l Disposal o r

Treatmen t

Location : : Date :

Date : i

E . TAN K

INFORMATION :

TAN K ID # DEQ-US T

PERMI T # TAN K SIZE I N GALLON S

: •• • ! • ' . • ^•

- 

# \-M^:<:: ^ 'i::Wf!M::^y-':;S:::< : PRODUCT : GASOLINE , DIESEL , USE D OIL , OTHER ? PRESEN T NE W CLOSUR E O RCHANGE-EN

- SERVICE ? TAN K REMOVA L CLOSURE

I N PLACE * CHANG E

I N SERVICE * TAN K T O B E REPLACED ? YE S N O

NOT E 1 : Wher e decommissione dtank(s ) ar e replace db y ne w undergroun dstorag e tank s th e US T permitte e mus t submi t aGenera l Permi t Registratio n For mt o Instal l an dOperat e UST s containin g informatio n o n th e ne w tank s 3 0 day s befor e installin g them . NOT E 2 : Submi t

asoi l samplin g pla n t o th e DE Q regiona l offic e an dreceiv e pla n approva l prio r t o startin g work

i f 1 ) tank i s t o b e decommissione din-place , 2 ) tan k content s ar e change dt o anon-regulate dsubstance , 3 ) tan k contain s aregulate dsubstanc e othe r than f petroleum , o r

4) tan k change dt o non-regulate duse . Augus t 200 7 Pag e 2 o f 7 DEQ-08-LQ-07 3F . DISPOSA LINFORMATION :

TAN K ID # TAN K

AN D PIPIN GDISPOSA LMETHO D SCRA P LAND

FILL OTHE R IDENTIF Y LOCATIO N & PROPERT Y OWNE R

;'• ' • ':'^ • V ' ' -:'^ \: . DISPOSA LLOCATIO N O FTAN K CONTENT S LIQUID S

- SLUDGE S

' ' - ^

. • • • • • •..'. . "- • NOT E 1 : Th e tank

contents , th e tan k

an dth e pipin g may b e subjec t t o th e requirement s o f

Hazardou s Wast e regulations . I f yo u hav e questions , contac t

th e DE Q regiona l offic e fo r you r area . NOT E 2 : Attac hcopies ofth e disposa l receipt s for th e tank s an dpiping . If

th e tank s ar e shippe doff-site for reus e provid e th e name , addres s an dphon e numbe r o f th e perso n o r

busines s receivin g th e tank s for reuse . NOT E 3 : Attac hcopie s ofth e disposa l receipt s fo r th e disposa l o r

treatmen t

o f liqui do r sludg e remove dfi'omth e tank s G . CONTAMINATIO N INFORMATION : TAN K ID # GROUN D

WATE R IN PIT ? PRODUC T

ODO RIN SOIL ? PRODUC T

STAIN S IN SOIL? NUMBE R

O F SAMPLE S LABORATOR Y (NAME , CITY , STATE , PHONE )

NOT E 1 : Attac hacop y ofth e laborator y report showin g th e result s o f

al l test s o n al l soi l an dwate r samples . Th e laboratory report mus t identif y sampl e collectio n methods , sampl e location , sampl e depth , sampl e typ e (soi l or water) , typ e o f

sampl e container , sampl e temperatur e durin g fransportation, type s o f tests , an dcopies o f

analytica l laboratory reports , includin g QA/Q C information . Includ e laboratory name , addres s an dcopie s o f chain-of-custod y forms . NOT E 2 : I f

contaminatio n i s detecte dan daLeve l 2 o r Leve l 3 soi l matti x cleanu p standar di s applie dt o th e site , attac hacop y ofth e soi l matti x analysi s includin g method s o f determinin g soi l type , deptht o groundwater , an dsensitivity o f uppermos t

aquifer . 

### r

Augus t 200 7 Pag e 3 o f 7 DEQ-08-LQ-07 3H . SIT E SKETCH : (Sho w locatio n o f adjacen t roads , propert y lines , structures , dispensers , & al l USTs . Sho w North , genera l directio n o f

groun dslop e an dsoi l sampl e locations . Sketc hdoe s no t nee dt o b e draw n t o scale . Yo u ma y attac ha separat e drawing. ) 

# u

Augus t 200 7 Pag e 4 o f 7 DEQ-08-LQ-07 3LSAFET Y EQUIPMEN T O N JO B SITE : LFir e Extinguisher : Combustibl e Ga s Detector : Oxyge n Analyzer : Type/Size : Model : Model:

- Recharg e Date : Calibratio n Date : Calibratio n Date : J . DECOMMISSIONING : Al l Tanks : N/A = No t

Applicabl e (Chec k

(V ) Appropriat e Box ) 1 . Al l elecfrical equipmen t grounde dan dexplosio n proof ? 2 . Safet y equipmen t

o n jo b site ? 3 . Overhea delecttica l line s located ? 4 . Subsurfac e electrica l line s of f o r disconnected ? 5 . Natura l ga s line s of

f o r disconnected ? 6 . N o ope n fire s o r

smokin g materia l i n area ? 7 . Vehicl e an dpedesttia n ttaffic conttolled ? 8 . Excavatio n materia l are acleared ? 9 . Rainwate r

runof f directe dt o tteattnent

area ? 10 . Draine dan dcollecte dproduc t fromlines ? 11 . Remove dproduc t

an dresidua l fromtank ? 12 . Cleane dtank ? 13 . Excavate dt o to p o f

tank ? 14 . Remove dtan k

fixtures ? (pumps , lea

k detectio n equipment ) 15 . Remove dproduct , fill an dven t lines ? YE S N O UNKNOW N N/ A

K . TAN K

ABANDONMEN T IN-PLACE : Al l Tanks : N/A = No t

Applicabl e (Chec k

(V ) Appropriat e Box ) 16 . Samplin g pla n approve db y DEQ ? Date : DE Q Staff : 17 . Contaminatio n concem s fully resolved ? 18 . Fil l Material ? Type : YE S N O UNKNOW N 

### N/A1

1

Augus t 200 7 Pag e 5 o f 7 DEQ-08-LQ-07 3

### L . TANK

REMOVAL : Al l Tanks : N/A = No t

Applicabl e (Chec k

(V ) Appropriat e Box ) 19 . Tank placemen t

are acleared , chock s placed ? 20 . Purge do r

ventilate dtank

t o preven t

explosion ? Metho dused : :•::§•: : S • * Mete r reading : '':::.?::' ^ 21 . Wer e chain s o r

stee l cable s wrappe daroun dtan k fo r removal ? 22 . Tan k removed , se t

o n ground , blocke dt o preven t movement ? 23 . Tan k se t o n truc k an dsecure dwithsttaps(s) ? 24 . Tan k labele dbefor e leavin g site ? . YES N O

/:•-.> : UNKNOW N 

### N/A1

M . SITE ASSESSMENT : Al l Tanks : N/A = No t

Applicabl e (Chec k

(V) Appropriat e Box ) 25 . Site assesse dfor

contamination ? Se e OA R340-122-034 0 26 . Soi l sample s take n an danalyzed ? 27 . Wa s contaminatio n found ? Date/Time : < : 28 . Wa s hazardou s wast e determinatio n mad e for tank content s (Liquids/sludges) ? YES N O UNKNOW N 

### N/A1

' . ,•::•• • 

### N . REQUIRED SIGNATURES : I hav e personall y reviewe dthi s decommissionin g checklis t an dsite assessmen t

report an dth e attachment s an dfm d the mt o b e tru e an dcomplete . Perriiitte e o r

Tan k Owner : (Pleas e Print ) Permitte e o r

Tan k Owner : Date :

(Signature ) I hav e personall y reviewe dthi s decommissionin g checklis t an dsite assessmen t

report an dth e attachment s an dfind the mt o b e tru e an dcomplete . License dSupervisor : " ••- : • ' -_ • • ; ' " ^ . - • • - -::••::..::.-:- : . .'•: . .:.:•:;:: ; •.••-.'• ^ : . > ; . ; .- , • ; (Pleas e Print ) Date : License dSupervisor : • (Signature ) I hav e personall y reviewe dthi s decommissionin g checklis t an dsite assessmen t

report an dth e attachment s an dfind the mt o b e tru e an dcomplete . Executiv e Officer : WiMm i License dServic e Provide r Executiv e Officer : License dServic e Provide r (Pleas e Print ) Date : (Signature ) Augus t 2007 Pag e 6 o f 7 DEQ-08-LQ-07 3

### 0 . REPOR T FILING : Thi s report

signe db y th e permitte e o r tan k owner, license dsuperviso r an dexecutiv e officer

ofth e Servic e Provider , complet e withal l applicabl e attachments , mus t b e filedwit

hth e DE Q regiona l offic e withi n 3 0 day s after th e excavatio n i s backfille do r

change-in-servic e i s complete . D o no t wai t unti l an y sit e relate dcleanu p projec t i s completed . Contac t ^ e DE Q regiona l offic e prio r t o filing thi s report

wher e specia l circumstance s exis t at th e site (suc ha s wate r

i n pit , remaining pocket s o f

contamination , etc.) . P . HEL P WIT H THI S REPORT : I f yo u hav e an y question s abou t thi s decommissionin g checklis t an dsit e assessmen t

report , pleas e phon e you r DE Q Regiona l Office . 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 for

call s mad e withi n Oregon . Undergroun dStorag e Tan k Programstaf

f wil l retu myou r

call s withi n 24 hours . Yo u can als o sen da

n e-mai l t o tanks . info(i5).deq.state.or.us . Ou r regiona l staf

f ar e als o availabl e t o answe r question s regardin g tan k

decommissionin g o r

change-in-servic e requirement s (se e belo w for telephon e numbers) . Q . COPIE S O FTH E GENERA LPERMI T T O DECOMMISSIO N O RCOMPLET EA CHANGE-IN-SERVICE : Obtai n copie s ofth e genera l permi t t o decommissio n o r

complet e achange-in-servic e condition s an drequirements , US T Progra mrule s an dlaw s an dUS T Cleanu p rule s an dlaw s at : 1 . An y o f

th e DE Q office s liste dbelow , 2 . B y callin g th e US T HELPLEM E at 1-800-742-7878 , 3 . Sen da

n e-mai l t o tanks.info(S).deq.state.or.u s o r 4 . Downloadin g fromth e US T hom e pag e at : http://wvyw.deq.state.or.us/lq/tanks/ust/index.htn i

NORTHWES T REGION : Clackamas , Clatsop , Columbia , Multnomah , Tillamoo k

& Washingto n Countie s

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



### EASTER N REGIO N / TH E DALLES 400 E . Scenic Drive , Building 2 - 30 7 Th e Dalles , O

R9705 8 Phone : 541-298-725 5 Fax : 541-298-733 0 

# w NORTHWES T REGIO

N 202 0 S W4t hAvenue , Suit

e 40( ) Portland , O

R97201-5884 hone : 503-229-526 3 Fax : 503-229-694 5 WESTER N REGIO N / COO S BA

Y 38 1 N SECON

D STREE T COO S BA Y 97420 Phone : 541-269-272 1 Fax : 541-269-798 4 WESTER N REGIO N / EUGEN E 110 2 Lincobi Street , Suit

e 21 0 Eugene , O R9740 1 Phone : 541-686-783 8 Fax:541-686-755 1 WESTER N REGIO N / SALE M 75 0 Fron t Stree t NE , Suit e 12 0 Salem, O R97301-103 9 Phone : 503-378-8240 Fax : 503-373-794

4

Augus t 2007 Pag e 7 o f 7 DEQ-08-LQ-07 3