DERR-2024-011188

Utah Department of Environmental Quality
UST Installation Inspection
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Ownerahlo of Tanks Location of Tank• -_..=,.;=.;;.;..;;=&;;...;::,.:;...;;..;:..;..;.;.;.;; _______ --+-_______ -=:.::..:::.-=..;:_;_;...;:.;...;..:::;.:.;.=.. _______ --'1
Owner Namo fv'x...:Jtu ~
_ Address l~ S ~\,,'-<. ~ <(' t \
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Contact \:t'.\ r-. \Art: Phone Y\C\ '\0141\t,
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Contact Phone
Tanka tnstalt.d. Uae •ddldonal moas for addltlon1f tank1, T1nk No. 1.A-TankNo.1.~ Tank No.~ r/,fk No.,c;
.Ji.ew Installation or Ue9rade
Tank Is New or Used <must be ro-certitled by manufacturer If 1t Is used)
Material of construction (FRP. Steel, Comoos,te etc )
S1nale--walled or Double-walled (If OW Indicate 1f drv or liauld-filled)
Substance to be Stored
Caoac,tv
Date lnstafled
Dato ore..jnstallatfon AJr Test passed
Pressure for ore-installation Air Test
Leak Detection Method to be used
Tvoe of Overfill Prevention Device to be used (shutoff. ball float, etc )
Tvoe of Solll Prevention Device to be used (spill bucket, sump, etc.)
Plnlna Information
Material of Construction (Flex Plastic, FRP, etc.)
Tvce {Pressunzed, Suctlon. Safe Suction, Gravity, etc.)
Leak Detection Method{s) to be used
Date pre-mstallatJon Alr Test passed
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Installation Snectflcatlons. Resoond to the followlna auestlons. Explain any "No" answers In the "Comments" section on 1>, 2.
Certified Tank Installer r/\:\-v"' Uu\\ Cert.#: TL 5'"6r,. Exo. Date. 3;1l/) !-
Certified Installation Comoanv ( ~ ~ l')<.,,0 Cert.#. IC l L, '\":}
I Eau1oment used to hft and lower tank is of adeauate s12e fi/y No
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Visual inspection of tanks reveals no damage re) No
Anv damaged components have been repaired Yes No
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I Tank and PIPlflQ excavations are free of debns ~ No
' Estimated deoth to groundwater <; 1 l ~\l\.~O...-f\laftv<. , /rhu,, Y 11' +o ~"·l
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, Tanks are olaced at suff\aent depth for traffic reauirements, groundwater conditions, and adequate plplno slooe (!§; No
, Deoth of backfill bedd1na for tanks (must be at least one foot)· ~ -~ ~ p J.. I Type of backfill material: (,, r ~ • 'l /
; Backf~I has been adeauatelv comoacted for full suooort alonq tank lenath at 5 and 7 o'clock Dcd "'h~ r.~, Yes No
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Anchonna method 1s adeouate for Qroundwater considerations Note method here; No
Hold-down straos are 1n olace accordinq to manufacturer's specifications ~ No
Distance from tank(s) to nearest orooerty line 5'V' I Distance from tank(s) to nearest structure -::>~ 1
1
1 Spaang between tanks ,s acceptable (at least 18 inches between tanks for stable wall conditions orat least 1/2 ,a.,_
times the tank diameter for unstable wall conditions) , \!.9 No
Anodes have been checked lo detenmne that the plastic wrapper has been removed Yes No
Tank and/or 0101na cathodic orotechon svstem has been checked to determine that 1t Is working properly Yes No
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Amount of tank deflection meets soec1ficallons. Readinqs· Initial IJh. " ..... • I( After backfilling Final.
Corrosion ProtectJon UDOrade. Resoond to the followlna auestlona. Exolaln anv •No" answers In the "Comments" section.
~ No
F1efd-mstalled cathodic orotect,on svstem 1s des1aned bv a corrosion expert (Includes sign-off by corr. expert) Yes No n/a
Protected svstem components are properly isolated from non-protected components, dispensers, structures, etc. Yes No n/a
1 Electrical continuity between anodes and orotecled components is verified Yes No n/a
I
1 Recufier 1s properly Installed on a crrcu,t that always has power (not shut off when facility power is off) Yes No n/a
; I (name) Pt.. r ~11 (. u .._ 1_ I I cerbfy !hall rnspected lhe above-named facilrly on r date l /0 /;) / ;:J 'f
lnsoector Sianalure --~i~~~~~>~d~ Cert. #: Tl :J 9 1
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Utah Department of Environmental Quality
UST F acllity Site Plat
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FcaelUty ID c;cco-FQ I
Pago~ of ~
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Sub Pump S
Tank Fill F
ATG Probe A
Inter Probe I
Vapor Rec V
Capped C UTM North,ng Easting Other s ec, 0 Show locatlons of all bu1ld1ngs, streets, tanks, pIp1ng, and dispenser islands Indicate the product in each tank Show locaoons of tank manways and 1denufy each submel'Slble pump, fill, ATG probe, vapor recovery. etc For ciosures: Indicate the type (soil. GW, USC). location, and dep<h of each sample collected by lhe certified sam er or the ins ctor Indicate the locations of an re rted PIO or FI0 readin s. Show locations of enUal rece tors
, Comments De ()ee,h~1 \J
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