DERR-2024-010221

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UNDERGROUND STORAGE TANK PERMANENT CLOSURE NOTICE (rev. 2/1/15) FACILITY ID# 1000999 .
…
State Use Only
Date Processed by
Date Mailed to LHD
LUST ID#
Date to LUST Review
Closure Notice prepared at the request of the owner/operator (identified below) by David Hansen
of (company name) Rockwell Solutions, Inc Phone # [phone]
Address 718 E Bridger Lane City Elk Ridge StateUT Zip84651
TANKS CLOSED
Piping Only Tank #
Please complete for each tank
Type (Steel,FRP,etc.)
Date Installed
Capacity (Gallons)
Substance stored*
Date last operated
Date Closed
Removed/In Place/ Change in
Service (CIS)?
*Indicate the specific substance stored in each tank to be closed (regular, unleaded, diesel, waste oil, etc.)
CLOSURE INFORMATION
Fuel was emptied Sludge was removed Tank was cleaned
Tank was: Purged Inerted Method Used:
Location of Closure Records: CCI, Inc office
For In-Place Closure: tanks filled with:
For Change-In-Service: Substance to be stored:
FACILITY INFORMATION
Tank Owner Mountain Star Medical Group Phone # [phone]
Address 60 E South Temple Street, Suite 1900 City Salt Lake City State UT Zip 84111
Facility Name Timpanogos Regional Hospital
Address 750 W 800 North City Orem State UT Zip 84057
Contact person Chris Bartholomew Phone # [phone]
Total number of regulated underground tanks at this site before closure 0
Total number of regulated underground tanks at this site after closure 0
TANK REMOVER Name David Hansen Cert. # TR0410 Exp. Date 1/1/26
Company Rockwell Solutions, Inc. Phone # [phone]
Address 718 E Bridger Lane City Elk Ridge State UT Zip 84651
SOIL/GROUNDWATER SAMPLER Name Austin Merrell Cert. # GS1945 Exp. Date 5/9/26
Company CCI, Inc Phone # [phone]
Address 1876 N 2700 West, Suite 5 City Provo State UT Zip 84601
LP8/15/2024
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DISPOSAL SITES USED
Location Name Contact Name Phone # Date Amount
Tank(s) NA Tank #
Product From Tank(s)
Contaminated Water
From Tank Cleaning
Sludge
Contaminated Water
From Excavation
Contaminated Soil

SITE ASSESSMENT
Complete the Facility Site Plat (Closure Notice) and Sample Information Table (Closure Notice) on pages 3 and 4 to show the locations,
depths, and other information on all soil/groundwater samples taken for closure. The samples must be consistently identified by sample ID #
on the site plat, table, and lab analysis report.

Completed Facility Site Plat (Closure Notice) is attached.
The following must be included (enter the distance, and direction (N,S,E,W) from the area of contamination or, where applicable,
use OH for overhead, NP for not present):
60 E Water Line >100 Sewer Line 40 SE Natural Gas NP Storm Drain NP Telephone >100 Electrical 70 E Property Line 12 W Buildings
Completed Sample Information Table (Closure Notice) is attached.
Certified lab analytical environmental sample results are attached.
Unified Soil Classification (USC) sample results are attached.
Chain of Custody form is attached.
Samples were properly: Collected Labeled Packaged Transported
Samples were in sight of the person in custody at all times or in a secured locked place.

I certify under penalty of law that the closure site assessment at this facility was conducted in accordance with 40 CFR 280.52, 40
CFR 280.72, and R311-205 U.A.C., and that any additional samples required by 40 CFR 280.52, 40 CFR 280.72 and R311-205-2(a)(1)
were properly collected.

Signature of Certified Groundwater/Soil Sampler
Full name of Certified Sampler Austin Merrell Date

If contamination at the facility is confirmed, any person providing remedial assistance for a fee must be a Certified UST Consultant. The
Certified UST Consultant providing assistance is:

CERTIFIED UST CONSULTANT
Name David Hansen Cert. #CC 0130 Exp. Date 1/1/2026
Company Rockwell Solutions, Inc Address 718 E Bridger Lane
City Elk Ridge State UT Zip 84651 Phone # [phone]

Please explain any unusual circumstances that occurred during the site assessment or closure:

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Facility Site Plat (Closure Notice)
The site plat must be drawn to an appropriate identified scale. It must show planned sampling locations, substances stored in tanks, and
other relevant information. Tank and sample identification numbers must be consistent with the information given on p. 1 and 4 of the
Closure Notice.
Facility ID: Drawn By: Date:
X = Sample locations (SS-#, WS-#, USC-#) Site Plat Must Indicate Actual Locations Of:
0 = Monitoring Wells (MW-#) √Current & former tanks, piping & dispensers
 = Soil boring (SB-#), or Geoprobe Boring (GP-#)√ Location of all samples to be taken
●= Water Wells (domestic, livestock, etc.)√ Buildings, fences, & property boundaries
Slope of Surface Topography: (N,NW,W,SW,S,SE,E,NE)√ Utility conduits (sewers, gas, water, storm drains, electrical, etc.)
Land Use At Site: Residential Commercial Industrial √ Depth to groundwater (if encountered)
Surrounding Land: Residential Commercial Industrial √Excavations, GW monitoring wells & soil stockpiles
North Scale: 1”= Feet
See Figure 1 (attached)
Water
Gas
Sewer
NORTH
Sample Location Timpanogos Hospital
750 W 800 North
Orem, Utah
Approx. scale in feet
00 20
Figure 1 Piping Closure Map
Timpanogos Hospital below
AST product lines
TB-S
GW-S
D-NE
D-SE
TB-E
USC-2
D-NW
D-SW
USC-2
rWate
Gas
Sweer
Stranorm Di
AST AST
rWate
sGa
The analyses presented on this report were performed in accordance with the
National Environmental Laboratory Accreditation Program (NELAP) unless
noted in the comments, flags, or case narrative. If the report is to be used for
regulatory compliance, it should be presented in its entirety, and not be
altered.
Client Service Contact: 801.262.7299
Attn: CCI, Inc.
1876 N 2700 W Bldg #5
Provo, UT. 84601
Work Order: 24G0657
Project: Timpanogos Hospital
7/19/2024
Approved By:
Reed Hendricks, Lab Director
9632 South 500 West Sandy, Utah 84070
Serving the Intermountain West since 1953
801.262.7299 Main 866.792.0093 Fax www.ChemtechFord.com
Page 1 of 5
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Chemtech-Ford Laboratories
Serving the Intermountain West Since 1953
Certificate of Analysis
9632 South 500 West
Sandy, UT 84070
O:[phone] F: [phone]
www.ChemtechFord.com
CCI, Inc.
1876 N 2700 W Bldg #5
Provo, UT. 84601
PO#:
Receipt:
Date Reported:
Project Name:
7/9/24 13:25 @ 7.2 °C
7/19/2024
Timpanogos Hospital
Sample ID: Timpanogos Hospital Below AST Product Lines
Lab ID: 24G0657-01Matrix: Solid
Flag(s)Units
Analysis
Date/Time
Date Sampled: 7/9/24 7:35
Preparation
Date/Time
Sampled By: Austin Merrell
Minimum
Reporting
Limit MethodResult
Inorganic
-7/15/247/15/24ASTM D2487-ModSCUnited Soil Classification [USC]
Project Name: Timpanogos Hospital CtF WO#: 24G0657
www.ChemtechFord.com
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xx
Chemtech-Ford Laboratories
Serving the Intermountain West Since 1953
Certificate of Analysis
9632 South 500 West
Sandy, UT 84070
O:[phone] F: [phone]
www.ChemtechFord.com
CCI, Inc.
1876 N 2700 W Bldg #5
Provo, UT. 84601
PO#:
Receipt:
Date Reported:
Project Name:
7/9/24 13:25 @ 7.2 °C
7/19/2024
Timpanogos Hospital
Sample ID: Timpanogos Hospital
Lab ID: 24G0657-02Matrix: Solid
Flag(s)Units
Analysis
Date/Time
Date Sampled: 7/9/24 11:35
Preparation
Date/Time
Sampled By: Austin Merrell
Minimum
Reporting
Limit MethodResult
Inorganic
%7/11/247/11/240.1 CTF800092.5Total Solids
Diesel Range
mg/kg dry 7/17/247/17/2454EPA 8015 CNDDiesel Range Organics
Volatile Organic Compounds
mg/kg dry 7/15/247/15/240.01 EPA 8260D/5030BNDBenzene
mg/kg dry 7/15/247/15/240.03 EPA 8260D/5030BNDEthylbenzene
mg/kg dry 7/15/247/15/240.03 EPA 8260D/5030BNDNaphthalene
mg/kg dry 7/15/247/15/240.03 EPA 8260D/5030BNDToluene
mg/kg dry 7/15/247/15/240.08 EPA 8260D/5030BNDXylenes, total
Project Name: Timpanogos Hospital CtF WO#: 24G0657
www.ChemtechFord.com
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xx
Chemtech-Ford Laboratories
Serving the Intermountain West Since 1953
Certificate of Analysis
9632 South 500 West
Sandy, UT 84070
O:[phone] F: [phone]
www.ChemtechFord.com
CCI, Inc.
1876 N 2700 W Bldg #5
Provo, UT. 84601
PO#:
Receipt:
Date Reported:
Project Name:
7/9/24 13:25 @ 7.2 °C
7/19/2024
Timpanogos Hospital
Report Footnotes
Abbreviations
ND = Not detected at the corresponding Minimum Reporting Limit (MRL).
1 mg/L = one milligram per liter or 1 mg/kg = one milligram per kilogram = 1 part per million.
1 ug/L = one microgram per liter or 1 ug/kg = one microgram per kilogram = 1 part per billion.
1 ng/L = one nanogram per liter or 1 ng/kg = one nanogram per kilogram = 1 part per trillion.
On calculated parameters, there may be a slight difference between summing the rounded values shown on the report
vs the unrounded values used in the calculation.
Project Name: Timpanogos Hospital CtF WO#: 24G0657
www.ChemtechFord.com
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