DERR-2024-011953

Utah Department of Environmental Quality
Permanent Closure Inspection
Facillt ID
Pae \
Ownershl of Tankl location of Tanks
Owner No~~ill 'fc, 1i i) d" \_) ( u(1,... _______ t--Lo"--ca_ti_o_n _N..;._am_e_..c:...:...__;_,.;_-->---..l.~).L_~_::._ ______ -1
tJ \0) Addr
\h State -t'N Zi Cit State
Contact Phone Contact Phone <;_ c., \ t,( t \ "1 '\ \
Tanka Cfoscd~ Us• addidonaJ for addltlon ■I tanka. Tan'k No.
allons
Material of Construction Steel. FRP, Com os1te, etc.
Substan~ Stored
Date Last Used
Date Pennanenu Closed
How Closed Removed, In P e In Service
On of tanks. losed Tanks ~ New Tanks:
Ta
UST Remover Cert.#· TR
Cert.#· GS
Owner/0 rator has an a roved Closure Plan Yes No
Product removed Yes No 8. Dis osal Site
Slud e removed Yes No D,s osal Site:
Tanks cleaned Yes No 8. insate dis osal site:
Non-ex loslve etmos here Inside tank obtained b : en obtained. / ~
Product fines were:
Tank dis e. ~),-
Sfte AIHunMnt
n the site lat : lt/J
Calibration s ecs:
Yes De th of Contamination. 0-3 Feet Greater than 3 Feet
Groundwater contamination Is evident: Yes De th to Water Table. /q-} () dlrectJon:
Number of sam les collected GW C. USC).. Certified lab·
Land Use of surroundin area. D Residential D Industrial Commercial D Other s ec
Show umple anatysJs Information below. Samples with the ume analysts can be grouped together. Include any samples taken by the
Ins or. Show Nm • lncludi USC locations and I on the site lat.
Inspector observed collection of samples:
Contaminated soil was over-excavated·
s
Yes
No
No
Com ounds anal ed Anal sis Methods
Inspector collected and submitted duphcate samples:
If yes, confirmation samples were collected.
,., Indicate the dlatance n feet ind dlrwctfon to tfle nearHt ~ tors. Show rece location• on th• 1Jte t.
Residences Commercial Bulldin s Pro e Line Active Water Well
Surface Water Sewer Line Water Line Natural Gas line
Tele hone Line Electncal Line Storm Drain Other:
, Inspector signature
certify that I inspected the above-named faclhty on (date)
Cert #: Tl J 0. ~
No
Utah Department of Environmental Quality
UST Facility Site Plat
NORTH
0
0 0
Sub Pump S
Ta~ Fill F
ATG Probe A
Inter Probe I
Vapor Rec V
Capped C UTM Northm Eastin Other s 0 ShoW locatJons of all buildings, 1treet1. tanks, plpmg, and d15penar islands Indicate the product m each tanlt Show locallons of tank manways and lden\Jfy each. submel"Slble pump, fin, ATG pmbe, vapor recovery, etc. For closures: Indicate the type (sou. GW, USC), location, and depth of each sample collecled by the certified sam er or the ins ctor Indicate the locations of an re rted PIO or FID readm s Show locallons of ential rece tors
Comments
s
S-te,:Ja1090II doc