DERR-2024-011044

Utah UST Program
Application for Certificate of Compliance Facility ID#
UST Owner Information UST Facility Information
Owner Name: Facility Name:
Address: Address:
City: State: Zip: City: State: UT Zip:
Contact: Phone: Contact: Phone:
DESCRIPTION OF UNDERGROUND STORAGE TANKS
Tank #
Date Installed
Capacity
Substance Stored
TANK/LINE TIGHTNESS TEST Indicate Pass or Fail for each tank and product line tested. Include a copy of the test.
Tank #
Tank Test
Line Test
TYPE OF FACILITY
Marketing facility, or non-marketer with facility average monthly throughput greater than 10,000 gallons.
Non-marketer with facility average monthly throughput less than 10,000 gallons.
COMPLIANCE WITH UST REGULATIONS
All Underground Storage Tanks (USTs) at this facility have been registered.
All UST registration fees and Petroleum Storage Tank Fund Fees have been paid.
Are your USTs currently in compliance with all Federal, State, and Local UST regulations?
Yes No If "No" describe items of non-compliance:
PREVIOUS POLLUTION INCIDENTS
Complete the Previous Pollution Incidents form to indicate whether a pollution incident has occurred at the facility.
FINANCIAL RESPONSIBILITY MECHANISM DECLARATION (check one only)
I choose to participate in the Petroleum Storage Tank (PST) Trust Fund.
•Indicate the financial responsibility mechanism to be used for cleanup costs not covered by the Fund.
•Indicate the number of above-ground tanks and non-regulated underground tanks at the facility.
Above-ground tanks and non-regulated USTs at the facility may be required to participate in the Fund.
I choose another Financial Responsibility mechanism for the USTs at this facility.
•Indicate the financial responsibility mechanism to be used:
•(For self-insurance or guarantee) Indicate your company’s fiscal year end date:
•(For Insurance) Indicate the date the policy is renewed each year:
The Certificate of Compliance cannot be issued until all documents have been submitted and the mechanism has been
approved. If the mechanism has already been approved, submit documentation of coverage for the new tanks.
I certify under penalty of law that the above representations made by me are true and correct.
Owner/operator Signature Date Signed
CofCapp 0717
84
%ULDQ-XEHU 
0100119
Logan Regional Hospital
500 East 1400 North
Logan
2
11/2023
12,000 gal.
Diesel
2
Pass
Pass
Intermountain Health
36 South State Street
Salt Lake City UT 84111
James Blankenau 801.484.6114
X Self funded
4