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
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