DERR-2024-004461

TANK INSTALLATION CHECKLIST
TO INSTALLER: After tank installation, deliver the Installation Manual with the completed Tank Installation Checklist to the tank owner. Retain a copy of
each for your records .
TO OWNER: After installation, retain the limited warranty, the Installation Manual and completed Tank Installation Checklist for future reference and to
facilitate any warranty claim .
INSTALLATION DATE(S): 09/19/2023 PERSON COMPLETING FORM : Jack Hardman
INSTALLATION ADDRESS: _12_7_4_S_. _H_w~y_1_8_9_H_e_b_e_r_C_it~y~, U_T_. _8_4_03_2 ____________ _
TANK INFORMATION TANK#1 TANK#2 TANK#3 TANK#4
Tank type-Single-Wall (SW), Double-Wall (DW) ow ow ow
Tank Usage (Fuel)-Fuel, DEF, Pipeline Sump Fuel Fuel Fuel
Tank Usage (Water)-Potable Water, Water Collect ion n/a n/a n/a
Tank Usage (Wastewater)-Grease Interceptor, Septic, Industrial Waste -n/a n/a n/a
water/Chemical
Tank Usage (Oil/Water Separator) n/a n/a n/a
Nominal Tank Diameter-give in feet 10 10 110
Nominal Tank Capacity-give in gallons or liters(and note which) ~Ok 12k/8k ~Ok
If applicable, UUULC # (read from tank label)-yes or no G10233287 G 10233269 iG 10233263
SITE INFORMATION (See Section 1) TANK#1 TANK#2 TANK#3 TANK#4
Primary backfill meets Appendix C requirements -yes or no yes ves ves
Secondary backfill material will be used-yes or no no no no
Secondary backfill meets our requirements -yes or no n/a n/a n/a
Geotextile will be used-yes or no ves ves ves
Excavation -shored or not shored not not not
Tank will see traffic loads (H20 or HS20)-yes or no ves yes ves
Hole cond ition -dry or wet drv (:Irv k:Jrv
Anchor ing system will be used -yes or no ves ~es ves
If applicable, anchor ing system used -deadmen or anchor slab deadmen !d eadmen deadmen
PREINSTALLATION INSPEOI0N AND TESTING (See Sections 3 and 4) TANK#1 TANK#2 TANK#3 TANK#4
Shipping damage -yes or no no no no
Loss of vacuum -yes or no no no no
Monitoring flu id visible on interior of tank -yes or no n/a n/a n/a
Monitoring fluid visible on exterio r of tank -yes or no n/a n/a n/a
Requirements met for double -wall tanks shipped under interstitial
~
es es es
vacuum -yes or no . If yes, record the va lue . 15 17 17
Record fluid level in reservoir for double -wall wet tanks n/a n/a n/a
If requi red, tank passed pressure/soap test-yes or no n/a n/a n/a
ZCL I XERXESe IM0G1119PP 37
TANK INSTALLATION CHECKLIST
INSTALLING TANKS (See Sections 5 and 7) TANK#1 TANK#2 TANK#J TANK#4
Record tank diameter measurement #1 (before installation) 119.75 119.5/119.5 119.5
Record final backfill bedding depth under tank -inches or centimeters 12 12 12
Record final tank spacing between tanks -inches or centimeters 3 7 ·37 37
Record final tank spacing from tank endcap to excavation walls -inches 48 ~8 48
or centimeters
If applicable, deadmen used-factory -supplied or other factory factory factory
If applicable, anchoring hardware -factory-supplied or other actorv actorv actorv
Record diameter measurement #2 (after straps are installed) 119.5 119.5/119.5 119.25
Subtract diameter measurement #2 from #1 and record .25 0 .25
Deflection measurement meets Table 1-6 requirements -yes or no 1ves ves ves
Voids under tank between ribs and under domes filled with backfill yes yes yes
and tamped -yes or no
Backfill placement and compaction meet requirements-yes or no yes Hs es
Pip ing connections meet requirements -yes or no 1ves es
Fittings and other metal components are coated for corrosion yes ) es
protection -yes or no ----
Record diameter measurement #3 (after backfilling to top of tank is 119.5 119.5/119.5 119.25
complete)
Subtract diameter measurement #3 from #1 and record .25 0 .25
Deflection measurement meets Table 1-6 requirements -yes or no 1ves yes yes
Tank was ballasted prior to bringing backfill to top of tank -yes or no no no no
After backf illing is brought to top of tank (See Sections 5, 6 and 8)
Tank was ballasted after bringing backfill to top of tank-yes or no ~es ~es ves
I yes Postinstallation tests were conducted for pressure -testable tanks -yes r es es
orno
If applicable, optional hydrostatic test was performed -yes or no no no no
If applicable , containment sump test was successful -yes or no 1Y es yes yes
Record final depth of backfill over tank-give in inches or centimeters ~8" 40"/42" ~1"
Record diameter measurement #4 (after backfilling is brought to 119.75 119 .25/119 .25 119
subgrade)
Su bract diamete r measurement #4 from #1 and record 0 .25/.25 ,5
Final deflection measurement meets requirements ofTable 1-6 -yes ves yes yes
orno
If applicable, type of surface pad used -concrete or asphalt concrete concrete concrete
If applicable, thickness of surface pad used -give in inches or f 6 6
centimeters and note which type
If applicable, record monitoring fluid level when backfilling & top slab n/a n/a n/a
installation are complete
38 IM0 G11 19PP ZCL I XERXES~
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TANK INSTALLATION CHECKLIST
SITE SKETCH (Ind icate specifics of tank installation.) ADDITIO NAL NOTES
Note any variations and/or deviations from
instructions (and attach written authorizations):
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VERIFYING SIGNATURES
CONTRACTOR TANK OWNER/REPRESENTATIVE
I verify that this information is a true record of the installa ti on of the tanks I verify that this information is a true reco rd of the installation of the tan ks
listed here . listed here, and that I have received a copy of the Installation Manual
and this Tank Installation Check li st.
Name : Jack Hardma n Name :
Telephone : [phone] Telephone:
Email : Email: ..__ __ -4·ack. haldman@p_eko_w.e.s_tin _c __ c_o . _.__ __ _
Address: P.O. box 677 Address :
St. Goerge , UT . 84771
Signature: Signature :
Date : Date:
TO INSTALLER: After tank installation, deliver the Installation Manual with the complete d Tan k Installat ion Check li st to the tank owner. Retain a copy of
each for your records .
TO OWNER : After installation , retain the limited warranty, the Installation Manual and comp leted Tank Installat ion Checklist forfuture reference and to
facilitate any warranty claim .
ZCL I XERXES@ IM0G1119PP 39