DERR-2024-005767

Utah DEQ Underground Storage Tank
I nsta I ratio:")::f::::[J Form
@y: petroleum lnstallation speciarists
State Use Onlv
Permit Required? E
Permit # t632-2024-2
Base Fee S soo
lnspection Fee* 5200 x 4 5800 PST
lnstall Fee Szoo x + S_ 800_fg!e.!_
52100 Date Approved & Paid
I Address: 3075 Haun Dr. West Jordan, UT. 84088
Certified Installers/Technicians on project
Name Thomas Dyckman Cert. # TL OZSS Exp. Daterr,, Dn)c
Name Ketby Taylor Cert. # T1367 Exp. Date 3l2St2O2S
Name Cert. # TL Exp. Date
Tank Owner:Smiths Fuel & Drug
Address:1550 S. Redwood Road Salt Lake City, UT. g4104
Contact Name: Roger Goff Phone# [phone]
Facility Name: Smith,s #21 4
Facility Address: 900 North Highway 90 Heber City, UT. 94032
@@n / Upgrade /Repair tnformation I Est. Date work will commence 4t812024
Tank #1 2 3 4
Capacity 20k 8k 10k 8k
Tank Material FRP FRP FRP FRP
Piping Material Flex Flex Flex Flex
Substance stored unleaded premrum diesel ethanolfree
Check if upgrade or repair only. EI (Describe details below)
Describe Details offn-s{aTDUpgrade/Repair in the box betow (submit a drawing/site map of work to ba done}
lnstallation of two UST's and all underground piping and 11 dispensers
Mail completed form to:
DEQ/DERR
Box 144840
Salt Lake City, Utah 84LL4-484O
195 N. 1950 W. 1" Floor
salt Lake City, Utah
Phone [phone]
Fax [phone]
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ENVIRONMENTAL RESPONSE
& REMEDIATION
ver.8/7/2016