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Home My WebLink AboutDERR-2024-008865Page 1 Version 5.19.2021V1 Utah Notification for Aboveground Petroleum Storage Tanks Division of Environmental Response and Remediation Underground Storage Tank Section P.O. Box 144840 Salt Lake City, Utah 84114-4840 Phone # (801) 536-4100 Fax # (801) 359-8853 Email: TankCompliance@utah.gov Web site: deq.utah.gov STATE USE ONLY Facility ID #: _____________ Date Received: ___________ Data Entry Clerk Initials: ____ This form must be completed for each location containing aboveground petroleum storage tanks (APSTs) that are regulated by the State of Utah. I.Ownership of tank(s)II.Location of tank(s) Owner Name _________________________________________ Mailing Address _______________________________________ City ____________________ State ___________ Zip _________ Contact______________________________________________ Phone # ____________________ Cell # ____________________ E-mail _______________________________________________ Facility ID # (unless new location) ____________________________ Facility Name _________________________________________ Street Address ________________________________________ County ________________City ________________ Zip _______ Facility Phone #______________ Latitude: ________________ Longitude: ________________ III.Type of Notification IV.Other New Notification Amended Notification Located on land within an Indian reservation or on other Indian trust lands. Name of Tribe:_____________________________________ Federally regulated underground storage tanks are at this location. If so, please enter the Facility ID assigned in the space above under Section II. V.Type of Owner VI.Type of Facility VII.Exempt Commercial Private Federal Government State Government Local Government Tribal Government Auto Dealership Contractor Federal – Non-military Federal – Military Gas Station Industrial Railroad Residential Trucking or Transport Utilities Other (explain) _________________________ Commercial Airport(fueling) Farm/Agriculture Petroleum Distributor/Refiner (SIC Code 2911 or 5171) Oil or Gas Production and Gathering Heating Oil used on premises Less than 501 gallons VIII.Contact Person in Charge of Tanks Name: Job Title: E-mail:Address: Phone Number (Include Area Code): IX.Financial Responsibility I plan to meet the financial responsibility requirements by using the following mechanism(s): (check all that apply) Bond Rating Test Commercial Insurance Guarantee Letter of Credit Local Government Financial Test Risk Retention Group Self-insurance (Financial Test) State Fund (Petroleum Storage Tank Fund) Surety Bond Trust Fund Other Method (explain) __________________________________ X.Certification (Read and sign after completing ALL SECTIONS of this notification form) I certify under penalty of law that I have personally examined and am familiar with the information submitted in Sections I through XI of this notification form and all attached documents, and that based on my inquiry of those individuals immediately responsible for obtaining the information, believe that the submitted information is true, accurate, and complete. __________________________________________________________________________________________________________ Name and official title of owner or owner’s Signature Date Signed Authorized representative (Print) Page 2 Version 5.19.2021V1 XI. Description of Aboveground Petroleum Storage Tanks (complete for each tank at this location) Tank Identification Number (use additional pages if more than 5 APSTs) Tank # Tank # Tank # Tank # Tank # 1.Tank system description (check all that apply) (if either of these apply, the ApST is regulated) Rests directly on soil (including gravel) Any portion of piping buried or touches soil (including gravel) 2.Status of Tank (check only one) Currently in Use Temporarily Closed 3.Date of Installation 4.Capacity (501 gallons and greater) 5.Tank Attributes (check all that apply) Asphalt Coated or Bare Steel Cathodically Protected Steel (impressed current) Cathodically Protected Steel (sacrificial anodes) Composite (steel clad with non-corrodible material) Concrete Double Walled Manifolded Compartmentalized Field – constructed Steel Secondary Containment Concrete Secondary Containment Earthen Secondary Containment Tank rests on cradles UL Listed APST Connected to an Emergency Generator Other, Specify Here ____________ ___________ ___________ ___________ ___________ 6.Overfill Protection (check all that apply) Automatic Shutoff High-level Alarm 7.Spill Prevention Single Walled Dry Connect Fitting Other, Specify Here ____________ ___________ ___________ ___________ ___________ Page 3 Version 5.19.2021V1 8.Vapor Recovery Attributes (check all that apply) Pressure Vent Valve on Vent Pipe Coaxial Drop Tube at Tank Two Point Vapor Recovery at Tank Emergency Venting 9.Piping Attributes (check all that apply) Bare Steel Galvanized Steel Fiberglass Reinforced Plastic Flexible Plastic Copper Cathodically Protected (impressed current) Cathodically Protected (sacrificial anodes) Double Walled Secondary Containment Airport Hydrant Piping Unknown Other, specify Here ____________ ___________ ___________ ___________ ___________ 10.Piping Flexible Connectors (tank end) Containment sump Booted Not in contact with soil Cathodically Protected (impressed current) Cathodically Protected (sacrificial anodes) 11.Piping Flexible Connectors (dispenser end) Containment sump Booted Not in contact with soil Cathodically Protected (impressed current) Cathodically Protected (sacrificial anodes) 12.Piping Delivery Type Safe Suction (no valve at tank) U.S. Suction (valve at tank) Pressure Gravity Feed Page 4 Version 5.19.2021V1 13.Substance Gasoline - Regular (up to 10% ethanol) Gasoline - Midgrade (up to 10% ethanol) Gasoline - Premium (up to 10% ethanol) Gasoline – Ethanol Free Gasoline Containing > 10% ethanol (specify amount of ethanol and grade of product) Diesel Off Road Diesel Biodiesel Diesel Containing > 20% biodiesel (specify amount of biodiesel) Kerosene Avgas Jet Fuel New Oil Used Oil Other, specify here ____________ ____________ ____________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ 14.Release Detection (check all that apply)Tank Pipe Tank Pipe Tank Pipe Tank Pipe Tank Pipe Tank Tightness Testing Automatic Tank Gauging Interstitial Monitoring Statistical Inventory Reconciliation Automatic Line Leak Detectors Line Tightness Testing