30-Day Notice Form Of Intent To Decommission Usts Or Complete A Change-In-Service

Download a blank fillable 30-Day Notice Form Of Intent To Decommission Usts Or Complete A Change-In-Service in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete 30-Day Notice Form Of Intent To Decommission Usts Or Complete A Change-In-Service with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

OREGON DEPARTMENT OF ENVIRONMENTAL QUALITY
UNDERGROUND STORAGE TANK PROGRAM
30-DAY NOTICE OF INTENT TO DECOMMISSION USTS
OR COMPLETE A CHANGE-IN-SERVICE
1. FACILITY (Location of Tanks) (Please Print) 2. PERMITTEE (Please Print)
Name:
_______________________________________
Name:
_______________________________________
Address: _______________________________________
Address:
_______________________________________
_______________________________________
_______________________________________
Phone:
_______________________________________
Phone:
_______________________________________
DEQ General Permit Operating Certificate Number: ___________________________
Work To Be Performed By: ___________________________________________
License # _________________
(Permittee, Tank Owner, Property Owner or Licensed Service Provider)
(Service Provider)
Phone: _____________________________
Mobile Phone: __________________________________
THIS FORM MUST BE SUBMITTED BY UST PERMITTEE 30 DAYS BEFORE START OF WORK
YOU MUST CONTACT YOUR LOCAL DEQ REGIONAL OFFICE 3-DAYS BEFORE STARTING ANY
DECOMMISSIONING WORK. (Phone numbers are listed on Page 2)
Will tank removal or potential cleanup affect adjacent property or Right-of-Way property? Yes ______ No ______
Date decommissioning is scheduled to begin: ______________________
PRODUCT: GASOLINE,
CLOSURE OR CHANGE-IN- SERVICE?
TANK TO BE
DIESEL, USED OIL,
REPLACED?
OTHER?
DEQ-UST
TANK SIZE
PRESENT
NEW
TANK
CLOSURE
CHANGE
YES*
NO
TANK
PERMIT #
IN
REMOVAL
IN
IN
ID #
GALLONS
PLACE♦
SERVICE♦
If decommissioned tank(s) are to be replaced by new underground storage tanks you must submit a General Permit
Registration Form to Install and Operate USTs for the new tanks 30 days before installing them.
♦ Submit a soil sampling plan to the DEQ regional office and receive plan approval prior to starting work if (1) tank is to
be decommissioned in-place, (2) tank contents are changed to an unregulated substance or (3) tank contains a regulated
substance other than petroleum.
Permittee: ____________________________________________________________
(Please Print)
Permittee: ____________________________________________________________ Date: ________________________
(Signature)
May 2
Page 1 of 2
Clear All Entries
Print Form

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 2