'-O^ 

DEQ 

state of Oregon 

Department of 

Environmental 

Quality 

OREGON DEPARTMENT OF ENVIRONMENTAL QUALITY 

Underground Storage Tank Program 

Undergroun d Storag e Tan k Service s 

SERVICE PROVIDER LICENSE APPLICATION 

For this license application to be valid the total fee, the list of UST projects completed and the list of 

licensed supervisors working for the service provider must accompany the license application. Renewal 

aoplications must be submitted 30 days prior to expiration. You should receive your license from DEQ 

within one tc'two weeks from the date you submit the complete application. 

Please retum this application, fee and attachments to: 

Department of Environmental Quality 

Attention: Business Office 

811 SW. Sixth Avenue 

Portland, OR 97204 

(^Questions? In Oregon, call 1-800-742-7878 

Outside Oregon, call 503-229-6652/FAX: 503-229-6977 

FOR DEQ USE ONLY LIC UST 

Date Rec'd.: 

Amount Rec'd: $ 

Check No.: 

Effective March 10, 2008 th e non-refundable license fee is $600 for 24 month s 

Check (•) the appropriate box below: This application is for 

I JNew License | Renewal License No.: Expiration Date: ^_ _ 

1. UST SERVICES SERVICE PROVIDER INFORMATION 

FIRM PROVIDING UST SERVICES 

Leaal Name^: 

Address: 

Citv. State: ) 

ZiD Code: 

Teleohone No.: . . 

Contact Person: 

E-Mail Address. 

CORPORATE HEADQUARTERS (If Different^ 

Name: 

Address: 

Citv. State: 

Zip Code: 

Telephone No. . 

2. OREGON CONSTRUCTION CONTRACTORJ-ICENSE 

CCB License No.:--:g":" --^ (if required for the type of work your firm performs) 

Check here if you are in the process of obtaining a Contractors License from the Oregon Construction 

Contractors Board (CCB). Call 503-229-6652 to provide the license number when complete. \ 

* As registered with the Oregon Corporation Division 

March 2008 Page lo f 2 05-LQ-077B 
UST Services Service Provider License Application 

3. TYPES OF SERVICES PROVIDED Check the box for each type of sen/ice your firm performs. 

• Note: you may be required to demonstrate that your firm has the necessary equipment available to perform 

listed services as part of an inspection or audit. 

Installation and Retrofit Decommissioning Tightness Testing Cathodic Protection 

SUPERVISORS Provide the name, type of license and license number for each UST Supervisor your firm 

employs. A supervisor must be on site during specified times or stop work. Attach additional pages as needed. 

Supervisor Name: License Number: Type of License(s): 

SERVICE AREA Areas of Oregon where your firm will provide services to the public. Check as many that apply 

or simply check Statewide. See map for definitions of DEQ regions. You must check at least one. 

Statewide 

Eastern 

Northwest 

Western 

M 

NORTHWEST REGION: 

Clackamas, Clatsop, 

Columbia, Multnomah, 

Tillamook & Washington 

Counties 

WESTERN REGION: Benton, 

Coos, Cuny, Douglas, Jackson, 

Josephine, Polk, Lane, Lincoln, 

Linn, Marion & Yamhill Counties 

EASTERN 

REGION: 

Baker, Crook, 

Deschutes, 

Gilliam, Grant, 

Hamey, 

Hood River, 

Jefferson, 

Klamath, Lake, 

Malheur, 

Morrow, 

Shemian, 

Umatilla, 

Union, Wasco, 

Wheeler & 

Wallowa 

Counties 

EXPERIENCE Attach a summary of UST projects completed in Oregon during the last 12 months. If this is a 

new application, on a separate page, describe your company's experience in conducting the specific type of 

services you propose to perform. 

Check here if your company has not worked on any UST projects during the last 12 months. 

inPLC liromnTioM 

Company or Individual Name/Address 

Sample Company 

1515 SE Champion Way 

Portland, OR 97333 

Type of Project 

Decommission 

Date Completed 

October, 2000 

7. CERTIFICATION 

" I, (your name). - ^ . - - - '^"':-' • •• - •' •':: • • :• • •" ••'"^ -• • 'J:. -:'' -. -; ' y ''••:••:.•.•' ':•, am ttie Chief Executive Officer (or legal 

equivalent) of (company name) •' ' •••••" •• .:•::'• ;':.^^".-:;'--:-- :•:' •. •-'•r'" ':, and do thereby certify that I 

have obtained a copy of the applicable laws and rules pertaining to the regulation of Underground 

Storage Tanks in the State of Oregon, and that I have read them and will direct the employees and 

principals of this company to perform the tank services rendered by this company In the manner 

that is consistent with their requirements." 

Signature: 

Name: 

J 

Date: 

Title: 

(Musi be principal in the finv) 

Page 2 of 2 

DEQ 

state of Onagon 

Department of 

Enviion menial 

Quality 

OREGON DEPARTMENT OF ENVIRONMENTAL QUALITY 

Underground Storage Tank Program 

Undergroun d Storag e Tan k Service s 

SUPERVISOR LICENSE APPLICATION 

Please return this application along with required fee and exam reportCs) to: 

Department of Environmental Quality 

ATTENTION: Business Office 

811 SW Sixth Avenue 

Portland, OR 97204 

(3)Questions? In Oregon call toll-free 1-800-742-7878 

Outside Oregon call (503) 229-6652 FAX (503) 229-6977 

Complet e th e followin g information : 

FOR DEQ USE ONLY LIC UST 

Date Rec'd: 

Amount Rec'd: 

Check No.: 

APPLICANT INFORMATION 

Your NAME: 

ADDRESS: 

'CITY: 

ZIP: 

STATE: : 

PHONE: . 

E-MAIL ADDRESS: 

EMPLOYER INFORMATION 

Company NAME: 

ADDRESS: 

CITY: 

ZIP: , 

STATE 1 

PHONE: 

E-MAIL ADDRESS: 

Effective July 6, 200 1 th e non-refundable license fee is $150 

for 24 month s for one or mor e of th e following licenses 

Check (• ) the appropriate box(s) below for each license you are applying for: 

EH UST Installation/Retrofit • New • Renewal License No.:. 

O UST Decommissioning • New • Renewal License No.:. 

• UST Tightness Testing • New O Renewal License No.:. 

• UST Cathodic Protection • New • Renewal License No.:. 

Expire Date: 

Expire Date: 

Expire Date: 

Expire Date: 

ATTACH the passing examination documentation for each license you are applying for. 

Important Note: There is a separate application form and license fee for Heating Oil Tank Services 

and Soil Matrix Cleanup Supervisor licenses. 

Applican t Signature: . Date : 

^^0 1 

For this license application to be valid it must be accompanied by the total fee and the passing score report(s) 

OU received from the test administrator, LaserGrade or Pearson VUE (formerly Promissor). License 

plications must be submitted to DEQ within 30 days of passing the qualifying examination. Renewal 

• applications must be submitted 30 days prior to expiration. You should receive your license(s) from DEQ 

within one to two weeks from the date you submit the application. 

Please notify bEQ immediately of any address changes so you do not miss importont bulletins! 

January 2008 Page 1 of 1 DEQ-05-LQ-078B