# '-O ^ DE Q stat e o fOrego n Departmen t o f Environmenta l Qualit y OREGO N DEPARTMEN TO F ENVIRONMENTA L QUALIT Y Undergroun d Storag e Tan k Progra m Undergroun d Storag e Tan k Service s 

## SERVIC E PROVIDE R LICENS E APPLICATIO N Fo rthi s licens e applicatio n t o b e vali d th e tota l fee , th e lis t o fUS Tproject s complete d an d th e lis t o f license d supervisor s workin g fo rth e servic e provide rmus t accompan yth e licens e application . Renewa l aoplication s mus t b e submitte d 3 0 day s prio rt o expiration . Yo u shoul d receiv e you rlicens e fro m DE Q withi n on e tc'tw o week s fro m th e dat e yo u submi t th e complet e application . Pleas e retu m thi s application , fe e an d attachment s to : Departmen t o fEnvironmenta l Qualit y Attention : Busines s Offic e 81 1 SW . Sixt h Avenu e Portland , O R 9720 4 (^Questions ? I n Oregon , cal l 1-800-742-787 8 Outsid e Oregon , cal l 503-229-6652/FAX : 503-229-697 7 FO RDE Q US EONL Y LI C UST Dat e Rec'd. : Amoun t Rec'd : $ Chec k No. : Effectiv e Marc h 10 , 200 8 th e non-refundabl e licens e fe e i s $60 0 fo r2 4 month s Chec k (• ) th e appropriat e bo xbelow : Thi s applicatio n i s fo r I JNe wLicens e | Renewa l Licens e No. : Expiratio n Date : ^_ _ 1 . US TSERVICE S SERVIC E PROVIDE R INFORMATIO N FIR M PROVIDIN G US TSERVICE S Leaa l Name^ : Address : Citv . State : ) Zi D Code : Teleohon e No. : . . Contac t Person : E-Mai l Address . CORPORAT E HEADQUARTER S (I fDifferent ^ Name : Address : Citv . State : Zi p Code : Telephon e No . .



### 2 . OREGO NCONSTRUCTIO NCONTRACTORJ-ICENS E CC B Licens e No.:--:g": " -- ^ (i frequire d fo rth e typ e o fwor k you rfir m performs ) Chec k her e i fyo u ar e i n th e proces s o fobtainin g a Contractor s Licens e fro m th e Orego n Constructio n Contractor s Boar d (CCB) . Cal l 503-229-665 2 t o provid e th e licens e numbe rwhe n complete . \

* A s registere d wit h th e Orego n Corporatio n Divisio n Marc h200 8 Pag e lo f 2 05-LQ-077 BUS TService s Servic e Provide rLicens e Applicatio n 3 . TYPE S O F SERVICE S PROVIDE D Chec k th e bo xfo reac h type o fsen/ic e you rfir m performs . •Note : yo u mayb e require d t o demonstrat e tha t you rfir m ha s th e necessaryequipmen t availabl e t o perfor m liste d service s a s part o fa n inspectio n o raudit . Installatio n an d Retrofi t Decommissionin g Tightnes s Testin g Cathodi cProtectio n SUPERVISOR S Provid e th e name , typ e o flicens e an d licens e numbe rfo reac h US TSuperviso ryou rfir m employs . Asuperviso rmus t b e o n sit e durin g specifie d time s o rsto p work . Attac h additiona l pages as needed . Superviso rName : Licens e Number : Typ e o fLicense(s) :

SERVIC E ARE AArea s o fOrego n wher e you rfir m wil l provid e service s t o th e public . Chec k a s man ytha t appl y o rsimpl ychec k

Statewide . Se e ma p fo rdefinition s o fDE Q regions . Yo u mus t chec k a t leas t one . Statewid e Easter n Northwes t Wester n 

# M NORTHWES TREGION : Clackamas , Clatsop , Columbia , Multnomah , 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 , Hamey , Hood River , Jefferson , Klamath , Lake , Malheur , Morrow , Shemian , Umatilla , Union , Wasco , Wheele r& Wallowa Countie s

EXPERIENC E Attac h a summaryo fUS Tproject s complete d i n Orego n durin g th e las t 1 2 months . I fthi s i s a ne wapplication , o n a separat e page , describ e you rcompany' s experienc e i n conductin g th e specifi ctype o f service s yo u propos e t o perform . Chec k her e i fyou rcompan yha s no t worke d o n an yUS Tproject s durin g th e las t 1 2 months . 

## inPL C liromnTio M Compan yo rIndividua l Name/Addres s Sampl e Compan y 151 5 S E Champio n Wa y Portland , O R 9733 3 Typ e o fProjec t Decommissio n Dat e Complete d October , 200 0 7 . CERTIFICATIO N " I , (you rname) . - ^

. - - - '^"':- ' • •

•- • ' •': : • • : • •• " ••'" ^ - • • 'J: . -:' ' - . - ; ' y''••:••:.•.• ' ':• , a m tti e Chie fExecutiv e Office r(o rlega l equivalent ) o f(compan yname ) • ' ' ••••• " • •.:•::'•;':.^^".-:;'--:-

- :•: ' • . •-'•r' " ': , an d d o thereb ycertif ytha t I hav e obtaine d a cop yo fth e applicabl e law s an d rule s pertainin g t o th e regulatio n o fUndergroun d Storag e Tank s i n th e Stat e o fOregon , an d tha t I hav e rea d the m an d wil l direc t th e employee s an d principal s o fthi s compan yt o perfor m th e tan k service s rendere d b ythi s compan yI n th e manne r tha t i s consisten t wit h thei rrequirements. " Signature : Name : J Date : Title : (Mus i b e principa l i n th e finv ) Pag e 2 o f2

# DE Q

stat e o fOnago n Departmen t o f Enviio n menia l Qualit y OREGO N DEPARTMEN TO F ENVIRONMENTA L QUALIT Y Undergroun d Storag e Tan k Progra m Undergroun d Storag e Tan k Service s 

## SUPERVISO R LICENS E APPLICATIO N

Pleas e retur n thi s applicatio n alon g wit h require d fe e an d exa m reportCs ) to : Departmen t o fEnvironmenta l Qualit y ATTENTION : Busines s Offic e 81 1 S WSixt h Avenu e Portland , O R 9720 4 (3)Questions ? I n Orego n cal l toll-fre e 1-800-742-787 8 Outsid e Orego n cal l (503 ) 229-665 2 FA X (503 ) 229-697 7 Complet e th e followin g information : FO RDE Q US EONL Y LIC US T Dat e Rec'd : Amount Rec'd : Chec k No. :

APPLICAN T INFORMATIO N Your NAME : ADDRESS : 'CITY : ZIP : STATE : : PHONE : . E-MAILADDRESS : EMPLOYERINFORMATIO N Company NAME : ADDRESS : CITY : ZIP : , STATE1 PHONE : E-MAILADDRESS : Effectiv e Jul y6 , 200 1 th e non-refundabl e licens e fe e i s $15 0 fo r2 4 month s fo ron e o rmor e o fth e followin g license s Chec k (• ) th e appropriat e box(s ) belo wfo reac h licens e yo u ar e applyin g for : E H US TInstallation/Retrofi t •New•Renewa l Licens e No.: . O US TDecommissionin g •New•Renewa l Licens e No.: . •US TTightnes s Testin g •NewO Renewa l Licens e No.: . •US TCathodi cProtectio n •New•Renewa l Licens e No.: . Expir e Date : Expir e Date : Expir e Date : Expir e Date : ATTAC H th e passin g examinatio n documentatio n fo reac h licens e yo u ar e applyin g for . Importan t Note : Ther e i s a separat e applicatio n for m an d licens e fe e fo rHeatin g Oi l Tan k Service s an d Soi l Matri xCleanu p Superviso rlicenses . Applican t Signature: . Date : ^^0 1 Fo rthi s licens e applicatio n t o b e vali d i t mus t b e accompanie d b yth e tota l fe e an d th e passin g scor e report(s ) O U receive d fro m th e tes t administrator , LaserGrad e o rPearso n VU E (formerl yPromissor) . Licens e plication s mus t b e submitte d t o DE Q withi n 3 0 day s o fpassin g th e qualifyin g examination . Renewa l •application s mus t b e submitte d 3 0 day s prio rt o expiration . Yo u shoul d receiv e you rlicense(s ) fro m DE Q withi n on e t o tw o week s fro m th e dat e yo u submi t th e application .

Please notif ybE Q immediatel yo fan yaddres s changes so yo u d o no t miss importon t bulletins ! Januar y 200 8 Pag e 1 o f 1 DEQ-05-LQ-078 B