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i <br /> i <br /> DEQ USE_QNLY UNDERGROUND INJECTION CONTROL DEQ DATE STAMP <br /> REGISTRATION PRE-CLOSURE NOTIFICATION <br /> <br /> Received: f <br /> {Submit two copies. See pages 3 and 4 for detailed instructions.} <br /> <br /> Amount Received; ~ Return form with your payment to: <br /> Oregon Department of Environmental Quality <br /> Attn: Business Office <br /> 811 Sw Sixth Avenue <br /> Portland OR 9?204 Registration <br /> ~ ~ <br /> 1. Number of injection systems closing: x $~00 = $ C~~~ a (Amount enclosed} <br /> i <br /> 1. Facility Legal Name: ~ ~ 2. Common Name: <br /> 3. Facility Physical Address: ~ , ~ 4. Facility Mailing Address: <br /> City, State, Zip Code: City, State, Zip Code: <br /> ~ e~ <br /> 5. Name of 4wnerlQperator: ~ ~ e~ ~~.-e.~ f <br /> ~ 6. Phone Numbex: ~ <br /> :Address: ~ ~ ~ s oc0..~~~` Fax Number: .l <br /> E <br /> City, State, Zip Code: ~ ( e-mail address: <br /> onsultant Phone Number ~..Z~, <br /> 7. Consultant Contact: ~ ~ 1 <br /> 1. Latitude (decimal format -see page 3}: ~ ~..a~~ ~ Longitude (decimal format--see page 3}:~~i~--~~ ~ ~ <br /> 2. If re istered list UIC number e..,11117-45. T e of UIC Systems}: ~ 2- Number of inj ectian systems: <br /> g ~ g yp <br /> E <br /> l <br /> 3. Injection/Dispasal System Design (check all that apply): <br /> ~:Drywell ar sump ~ Auto floor drain ~ Cesspool D Sewage drill hole D Septic tankldrainfieldlleachfield ~ Other ' <br /> 4. Attach a site map showing UIC locations}, facility buildings .and their use, parking areas, roads and water features. l~Attached ~ <br /> 5. Year of UIC construction: Proposed date of injection system closure: ~ 1,~, <br /> List all UYCs on next a e. ~ ~ ` ~ ~ <br /> Pg <br /> 6. SICINAICS Code: Nature of business at facility: ! <br /> 7. Closure plan (check all that apply, or attach a brief description of how the UICsa will be closed, associated with types}: <br /> I <br /> Sample Fluidslsediments ~ttach to a municipal system <br /> Appropriate disposal of remaining fluidslsediments ~ C1ean out <br /> D Remove contaminated soil O Install permanent plug <br /> ~ Conversion to other well type D Other (describe}: ~ <br /> D Pump outlfill with racks and seal <br /> i <br /> 8. A sampling plan for UIC closure is required and must be approved by DEQ before closure may commence. The plan must also be overseen by a <br /> registered Professional Geologist, Engineering Geologist, or Professional Engineer. ~j Sampling plan attached <br /> 9. List any other DEQ or public agency permits applied for or issued to this facility: <br /> 14. Note past site uses: <br /> 11. If SARA Title III facility: List materials handled, stored, or used: <br /> 12. Note nearest brownfield or remediation site within one-half mile: <br /> ESCIILUST # and name (attach map from Proffer -see reverse side}: <br /> 13. DEQ regional contact person: <br /> p ~ ~ acs ~ ~ ~ a ~ ~ ~ ~ ~ ~ ~ ~ t~ ~ ~ ~ w ~ ~1cac~~t ! <br /> r ~ <br /> E <br /> E <br /> P `I <br /> f <br /> u~c iaaasw-c~o(t} (osios~~l 1 of 4 DEQ-08-WQ-039 <br /> • ~ i <br /> <br />