DERR-2024-011212

Utah DEQ Underground Storage Tank
lnstallation Notification Form
www.deq.utah.gov
i/New UST lnstall Upgrade/Repair
lnstallatlon Company:Westech Equipment
Facility
Contact Name:Ted Soffe Phone:[phone]
Address:195 West 3900 South
Permit Required? tr
Base Fee S 500
lnspection Fee* 5200 x_ S
PST lnstall Fee s200 x_ s
Total S
Date Approved & Pald
*Aoolles ln non-LHD contract areas
Permit #
Certmed hstallerc/Technicians on prolect
Name Sean Jardine cert. #rL 0066 Exp. Date 9 _ ts- LO L6
Name Taber DeHart Cert. #rL 0429 Exp. Date 0311512025
Name Cert. # TL Exp. Date
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Tank Owner:.r
Address:
,);^ a'toContact Name:Phone#
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Faclltry Name:'
Facillty Address:
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lnstallatlon / Upgrade /Repalr lnformatlon Est. date work wlll commence:
Tank #L
Capacity L0.ooo
Tank Material ,'R.P
Piping Material ' fl<.x Dtn)
Substance stored UruL
Check if upgrade or repair only.(Describe details below)
beloql (Submlt a drawlng/site map of work to be done)
I
Descrlbe Details of in the box
't'!4 A
JI I
Maitcompleted form to:
DEO/DERR
Box 144&40
salt Lake city, utah 84114-4840
195 N. 1950 W. l" Floor
Salt Lake City, Utah
Phone [phone]
Fax (801) 3s9-8853
EHVIRSH ME I{TAI,. R E$FQTII $Eil FEI'IEDIATIOH*
Ver.
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