DERR-2024-009949

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S'i:ate Use Onlv
Installation Notification Fo r m Perm it Required? □ www.undergroundtanks.utah.gov Permit#
Facility ID ) (JOO ~z.t New UST Install [ U
Base Fee $ 500
pgrade/Repai r D(l Inspection Fee* $200 x _ $
Installation Company: {St'.5co T 11 .:, PST Install Fee $200 x _ $
Total $
e: ~/'2.-'l 2~'1 'f"'f Date Approved & Paid
Uf-ff'foS"Lf *Applies i n non-LHD co ntract area s
Certified installers/Technicians on project
Cert.# TL 65 S 7 Exp. Date 3/11/z_t
Name Cert.# TL Exp . Date
Name Cert.# TL Exp. Date
Tank Owner: 0 C(C /cs,lfJ di. l<-f I
Address: 777 IV. SJ...k. SJ. 6 Ye1-t, (.JI-~t.tos7
Contact Name: I Phone#
Facility Name: .:::} etc /csf\s 1:1 l'f I
Facility Address: 777 Iv. 5J.,,k St. 6ro~, ( Jf-?r'f0S7
Installation/ Upgrade /Repair Information I Est . Date work will commence: &-°/1/Z.'!
Ta nk# z
Capacity
Tank M aterial
Piping Material
Substance stored Pr,~,.,~
Check if upgrad e or r e pair only. ~ (De scribe details below)
Describe Details of Install/Upgrade/Repair in the bo}{ below (Submit a drawing/site map of work to be done)
/l'l)iu( 5'p,'// hvck~I ~"' Pnn.,~"" -f.,,, k . .
M ail completed form t o : 195 N. 1950 W. 1st Fl oor Q U t Ml [.1 f p/•,H 'iMl::H l of
D EO/D ERR Sal t Lake Cit y, Uta h ~t<!V l f;{)pJH','.:f·-.fi\1-L {;1 U 1\l. l T Y
Box 14484 0 Ph o n e (8 01)536-4100 ENVH~Ol\l M~ f\11'/.\L 11 ESP·O i'il$~
Sa lt Lak e Cit y, Ut ah 84 114-4840 Fax [phone]< R[::f"'I E I) 11\'f(.OM
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Ver. 8/1/2016
8/2/2024