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<br />Oregon Department of <br />UNDERGROUND STORAGE TANK DECOMMIS'. <br />FACILITY: (Location of Tanks); <br />Name: Former Chevron Station/Courthouse Square <br />Addressc 595 Court Sfireet <br />Salem, Oregon <br />~hone: ' S03-373-4424 <br />DEQ Facility ID Number: <br />vVork To Be Performed By: Foss Environmental _ __ <br />(Owner or ~icensed $ervice provider) <br />'hone: 503-978-7282 Mobile Pho~e: <br />FORM MUST BE SUBMITTED BY UST OWNER OR OPERATOR 30 DAYS BEFORE START OF WORK <br />YOU MUST CONTACT YOUR LOCAL DEQ REGIONAL OFFICE 3-DAYS BEFORE STARTING ANY <br />DECOMMISSIONING WORK. (Phone numbers are listed on reverse) <br />Will tank removal or potential cleanup affect adjacent property or Right-of-Way property? Yes No X <br />Date decommissioning is scheduled to begin: October 31. 1997 <br />Tank DEQ <br />UST <br />i <br />P Tank Size <br />in <br />) <br />G <br />ll Product: Gasoline, <br />Diesel, Used Oil, Other? Closure or Service Change? <br /> <br />Tank Closure~ New ~ Tank to be <br />Replaced? <br /># erm <br />t <br /># ons <br />a <br />( <br />Present <br />New Removal Inplace Product * <br />Yes <br />No <br />UST-7 1,100 ? X X <br /> <br /> <br /> <br /> <br />* If decommissioned tank(s) are to be replaced by new underground storage tanks you most submit a new <br />permit application containing information on the new tanks 30 days before p(acing them in service. <br />~ Submit a soil sampling plan to the DEQ regional office and receive plan approval prior to starting work if 1) <br />tank is to be decommissioned in-place , 2) tank contents are changed to a non-regulated substance, or 3) tank <br />contains a regulated substance other than petroleum. <br />~ <br />Signatare: ~ , Date• f/ 1. :~ y~ ~` <br />, (Owner or, Oper ) <br />August 23, 1994 UST Decommissioning/Change-In-Service 30 DAY NOTICE Page 1 of 2 <br />Oregon DEQ <br />