DERR-2024-004781

only;
tr
tr
Ts temporarily closed and empty; leak detection not required.
USTs temporarily closed, locked and
(c
3939 S HARRISON BLVD
Tank is in use.
lf not in use. oive date last used and deoth of oroduct in
Material of consbucfion of tanks
Type of Spill Prevention devlce. Note on furm
of less than 25 oallons. lf so. no
containment bucket is clean. drv. and free
bansfers of less than 25 oallons. lf so. no overfill
can be seen and heard. and alarm is deadv marked.
Conosion Protection method used on tanks
method used on flex connectors. swino ioinE. etc.
lndicate dates of uoorades- linino. tank or
are available (within six
FlexGonnectors/SwlngJolnts NtlY tN c.67llo<,Y Atunk
For lmpressed Cunent Systems: The results of the last three equipment
Site Drovlng (North t )
Dst ibution: White- OERR, YelloF lnspector, Pink- Facility/Omer - Ldcfiecko7o3.doc
* g,.oo/trn {ett t/W0",,12r)rt^r1 3"7-54o{
Tank #:
Product
3
550
Diesel
Utah UtT Program
nk and Piping Leak Detec FacilitylD 1200090
lr4etrod tsed fq tanks: MTG tuethod used for oioim: Suction lnterstitial DW
Ivhruf acturer, nan'B and nodel nunber of system tem3d party cert. available Yes M
Cirde Yes or !b for each ouestion. ln the lat colum n exoldn ard ide ntifv hr tank
Fbcords on site docunent thd the systemis proper! installed, calibrated, and
Dvice docunBnhtion b availableon-site (owner's nenLal, etc
Quipnent rced to acqdre data, tale redings, perform test is dequate, accessible
f mctional. lrcl. ATG corsole, dipstick, etc.
Dcunentation of valid testing or nonitoring is available for the bst 12 nonhs. Slpw
or nmitorho results in orid below.
the probe is located at the center d the hnk. lf not, the tilt correction factor for each
hnk is shown on the tark
'14'lhe tankwas f illed to atleastthe nhinumlevd required by the nanufacturer's
equipnent potocol to ensure a vald leaktest and thetanksize is w ithin the allowed
Wper and lory er sLe lirits.
Secordary barrier is properly placed ard corstructed, designed for gw
consideratims, has an acceptable perneation rate, is conpatide w ih the substance
stored, is nm-conodiUe, and is nct in the 25-yr f loodplain (per site assessnBnt).
hvenbry readings f or prodrct inp.rts ard w itHrawals are properly obtained ard
recorded. Fbadirps are properly reconciled.
Fbcords include he proper runber of water readirps, ard w ater readings are used to
adiust inventorv balances as necessa
An appropriate tank calbratim chart is rsed and is arailable fq revieff.
have current calbratim stickers or
Dop tr-bes are present and extend to w lhin one foct of the tank bottom
Shorrr results of monitoring for each tank for the last 12 months. lndicate pass, fail, no results, or inconclusive.
Tank and Line Tlghtness Testing;"'Line Led( IbtectorTestlng:
Date of last tiohtness test f or tanks:
Mne and certficatim nunber d
Date of lat tiohtness test for oioho:
Mne and certlicatim nunber cf tester:
l t.lct ( <t
Date of last leak detector oerf ornance tesl
Safe Suction pping: Docunentation is available and verif iabb to slpw that pifing operates at less than atnospleric
pressure, has only me check valve (under punp), and has propa slope of piping.
2- #'
Facillty lD: 1200090 Facllity Name: I Y-DEE HOSPITAL CENTER
Owner Name: MCKAY DEE HOSPITAL CENTER Street Addressr 3939 S HARRISON BLVD
OwnerAddress: ATTN SCOTTANDERSON OGDEN UT 84409
OGDEN UT 8/t409 UTM Coordlnates
420,160.45 4,560,301.44 Hand Held GPS with Base Station Con
Tank lD: 1
Federally Regulated Tank: Yes
Tank Status:
Date lnstalled:
Date Closed:
Tank Capacity:
Tank Material:
Tank Material:
Pipe Material:
Pipe Material:
Pipe Flex Connector's:
Pipe Type:
Substance Stored:
Overfill lnstalled:
Spill lnstalled:
Cathodic Protection Met: Yes
Permanently Out of Use
4/30/1968
8t29t2002
25000
Lined lnterior
Copper
Cathodically Protected
Safe Suction
Diesel
Yes
Yes
Yes
Yes
Defened
Permanently Out of Use
1t1l't986
3128t',t994
500
Asphalt Coated or Bare Steel
None
Galvanized Steel
None
U.S. Suction
Tank lD: 3
Federally Regulated Tank: Yes
Tank Status:
Date lnstalled:
Cunently in Use
4t12t1994
Composite (Steel w/ FRP)
None
Flexible Plastic
Double-Walled
Safe Suction
Diesel
Yes
Yes
Yes
Yes
lmpressed Current Cathodic Protec Tank Material:
Date Closed:
Tank Capacity: 550
Tank Material:
Pipe Material:
Pipe Material:
Pipe Flex Connector's:
Pipe Type:
Substance Stored:
Overfill lnstalled:
Spill lnstalled:
Cathodic Protection Met: Yes
ln Compliance:
On PST Fund:
Tank Status:
Date lnstalled:
Date Closed:
Tank Capacity:
Tank Material:
Tank Material:
Pipe Material:
Pipe Material:
Pipe Flex Connecto/s:
Pipe Type:
ln Compliance:
On PST Fund:
Other Financial Mechanism: No
Tank Release Detection: ATG
Pipe Release Detection:
Defened
Tank lD: 2
Federally Regulated Tank: Yes
Other Financial Mechanism: No
Tank Release Detection:
Pipe Release Detection:
lnterstitial
Deferred
Defened
Other
Substance Stored: Diesel
Overfill lnstalled: No
Spill lnstalled: No
Cathodic Protection Met: No
ln Compliance: No
On PST Fund: No
Other Financial Mechanism: No
Tank Release Detection:
Pipe Release Detection:
Wednesday, April 14, 2004 Page 1 of 1
Locatlon of Tanks Efstate use
Number of tanks at the
lndicate if tank is siphoned or compartmented. Show related tanks.
Tank is in use.
lf not in use, give date last used and depth of oroduct in tank.
Material of construction of tanks
Type of Spill Prevention device. Note on form if tank is filled by transfers
of less than 25 qallons. lf so, no spill prevention is
containment bucket is clean. drv. and free ol
Type of Overfill Prevention device. Note on form if tank is filled by
transfers of less than 25 qallons. lf so. no overfill orevention is
lf an overfill alarm is the primary overfill device: Alarm is located where it
can be seen and heard. and alarm is
Protection method used on tanks
Corrosion Protection method used on
Corrosion Protection method used on flex
containment sumps are present at tanks and
Containment sumps are sealed, free from water. oroduct. etc.
results of the last two cathodic protection tests are available (within six
rl", c#llFtBrs/ Swing Joints Atrank
Tester UT Date At
For lmpressed Cunent Systems: The results of the last three equipment
checks are available (required everv 60
Utah UST Program
Release Detection lns Ghecklist
N Site Drawing North I
) tr E\t-t-l \-N'l
l, rl f;.jA RECEIvED
\\{\ s rul-62005
l-[ $"1 DEe
\9
:nvrrrr,m€'.lslRes,onse & Bemediation
Emergency generator tanks only; leak detection
tr USTs temporarily closed and empty; leak
tr USTs temporarily closed, locked and secured.
Distribution: White- DERR, Yellow- lnspector, pink- Facility/Owner LdcheckoSo4.doc
Utah UST ]Program
Release Detection lnspection Ghecklist
Complc*e for each tank f the faclllty has mor€ than 4 tank8, complete the lnlormation for addltlonal tanks on a separate form.
Number of tanks at facility:
Tank lnstallation Date
Capacity of tank (in gallons)
lndicate if tank is siphoned or compartmented. Show related tanks.
Tank is in use (Yes / No). lf not in use, give date last used
lf not in use, depth of product in tank (in inches)
An*or the lollowing for dl tanks. Note any oxceptlons in th€ last column.
Current year tank tags are in place
Material of construction ol tanks
Material of construction of piping
tank is filled bv translers of less
lf so. no soill orevenlion is required.
it can be seen and heard. and
Corrosion Protectlon. Anewer the lollowlng tor all tank. Note any exceptlons in ths last column.
Corrosion Protection method used on tanks
Corrosion Protection method used on piping
Corrosion Protection method used on flex connectors
Enclosed containment sumps at tanks (subpump) and dispensers
lndicate dates ol upgrades- lining, tank or piping cathodic protection.
Ce$odic Protrctlon Toetlng. thow tre results of the most r€cont test tor cach tanh llne, or llex EonnGetor'
Flex Connectors suboumo
Tester Date
For impressed current system: The results of the last three equipment
5- /z-o4
Distribution:, Pink-Facility/Owner
Etrtvt TAL
September 17,2002
Mr. Gary Harris
Utah Department of Environmental Quality
Division of Environmental Response and' Remediation
Underground Storage Tank Section
168 North 1950 West, First Floor
Salt Lake City, Utah 84114
RE: Closure Notice, Former McKay-Dee Hospital
3939 Harrison Boulevard, Ogden, Utah
Facility I.D. 1200090,
IHI Project #02E-7050
Dear Mr. Harris:
Enclosed you will find a copy of the Closure Notice for the 25,000 gallon diesel tank removed at
the former McKay-Dee Hospital. I have also attached a narrative description of the removal.
Since the tank was in good condition at the time of removal and all the closure samples showed
that no release has occurred, we are requesting that the site be closed.
If you have any questions, please feel free to call me at [phone].
Sincerely,
tL000qc
R ONM
I
EN
Christopher J. Nolan
Senior Geologist
[Enc.] Closure Notice
Analytical Results
Chain-of-Custody Documentation
Narrative Description
Rffi#HIVHM
.ltlq{...'.."
DEO
Environmental Response & Remediation
TELEPHONE: [phone] FM: 801-466'9616 E'MAlt: [e-mail]
PHOENIX DENVER
640 EAST WILMINGTON AVENUE
SALT LAKE CITY
SALT LAKE CITY, UT 84106
EMERYVILLE
UNDERGROUND STOR ^'lRevised 0u01/g7)
Facility ID #1200090
Closure Notice prepared at the request of the owner/operator (identified below) by Chris Nolan
of (company name) IHI Environmental Phone # ( 801 \ 466-2223
Address 640 East Wilminston Avenue City Salt Lake Citv State UT Zip 84106
FACILITY INFORMATION
Tank Owner IHC Health Services Iilhone # 801 442-3878-
[ ] sole proprietorship [ ] parrnership I X ] corporation
Address 36 South State Street 23'd Floor City Salt Lake CiW state uT zip 8411I
Facility Name Former McKay Dee Hospital
Address i9i9 Harrison Blvd.City Osden State UT Zip 84403
Contactperson hone#( 801 ) 387-5403
Number of regulated tanks at the facility before closure: 2
Number of regulated tanks at the facility after closure: I
TANKS CLOSED
Tank #I 2
Date Installed 1969
Capacity 25,000
qallon
Substance stored'Diesel
Date last operated 7102.
Date closed 8129/02
How closed
(Removed/In olace)Removed
* Indicate the specific substance stored in each tank to be closed (regular, unleaded, diesel, waste oil, etc.)
TAI\K REMOVER Name Reed Arnold Cert. #_____TR-0 3 05-Exp. D ate
-1
0 I | 5 I 2002
Company National Tank and Moni hone # ( 801 ) 280-3324
Address 8370 South 4152 West City West Jordan State UT Zip 84088
SOIL/GROUNDWATER SAMPLER Name ChristopherNolan Cert. #__.1GS !-[Q!__Exp.Date 2104
Company IHI Environmental Phone # ( 801\ 466-2223
Date Processed_Jfl ' I:_ZZ By
Date Mailed to LHD
Samples in LUST File #
Samples to LUST Review
LUST Stanrs
Address 540 East Wilminoton Avenue City Salt T.ake Citu State_lf[_Zip 84106
-
IX] Fuel was emptied IX ] Sludge was removed [X] Tank was cleaned
Tank was: [ ] Purged [X] Inerted Method Used:Drv Ice
Location of Closure Records Mr. Scott Andersen. McKay-Dee Eneineerine Depafi. [phone]
For In-Place Closure: tanks filled with__N/A _
For Change-In-Service: Substance to be stored N/A
DISPOSAL SITES USED:
Is any contaminated soil which was over-excavated still on-site? Yes No X Not applicable
Was Free Product encountered during closure activities? No If yes, please indicate thickness, Inches
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.
txl 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):
<4 Water Line_Sewer Line-Natural Gas-Sf,Storm Drain Telephone-Electrical-Propefi LinelO ft Buildings
IXI Completed Sample Information Table (Closure Notice) is attached.
tX] Certified lab analytical environmental sample results are attached.
txl Unified Soil Classification (USC) sample results are attached.
txl Chain of Custody form is attached.
Samples were properly: [X] Collected [X] Labeled [X] Packaged [X] Transported
tX] 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
R311-202 (parts 280.52 and 280.72) and R31L-205 U.A.C., and that any additional samples required by R311-202
parts 280.52 and 280.72 and R311-205-2(a)(1) were collected.
Signature of Certified Groundwater/Soil Sampler
Full name of Certified Sampler
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 CONSTJLTANT Name Cert.#_Exp. Date
Location Name Contact Name Phone #Date Amount
Tank(s)Durbano Metals 621-5221 8t30102 Tank #
Product From Tank(s)National Tank Reed Arnold 280-3324 8/29102 600 gal.
Contaminated Water From Tank Cleaning National Tank Reed Arnold 280-3324 8/29/02 50 gal.
Sludge National Tank Reed Amold 280-3324 8t29/02 30 gal.
Contaminated Water From Excavation N/A
Contaminated Soil N/A
Christopher J. Nolan D*e 9116102
Company
city salt Lake citv state uT zip 84106
2
Address
FACTLTTY SrrE PLAT (CLOSURE ng)
The site plat must be drawn to an appropriate identified scale. It must show actual sampling locations, substances stored
in tanks, and other relevant information. Tank and sample identification numbers must be consistent with the
information given on p. I and 4 of the closure notice
Facility ID #_ l2QqQ.2Q_Drawn By Christopher Nolan Date 9/t2to2
NORTH
SS-f * ll'9
x usc- I
)
J
.t
\9
o
8
ID-
c.l
AS,.HPA
Scale: l"- 20 Feet
N\
\\-
cLo( u' oY --' f o",'a!\1g
(
Nq
\,
5e V)al
,U
o
tr
llth
d.l
)
aU
;!)%v*nop
\,
3
H
'tl
t_
s
.3
\
,r\
3$JA
,)1
S,{
3p5S-2 a.BI
ASPNNO
Groundwater not encountered
Sample SS-1 collected at 12.5 feet bgs
Sample SS-2 collected at 13 feet bgs
Sample locations (SS-#, WS-#, USC-#)sample locarlons (55-F, ws-#, usc_#)
- i = Monitoring Wells (MW-#,)
O = Soil boring (SB-#), or Geoprobe Boring (Gp-#)o = Water Wells (domestic, livestock, etc.)
Slope of Surface Topography: (N, NW, W, SW, S, SE, E, NE)
Land Use At Site: _ Residential X Commercial Industrial
Sunounding Land:
-X_
Residential X Com*"rcGl Industrial
Site Plat Must Indicate Actual Locations Of:fI Current & former tanks, piping & dispensers
lI Excavations, GW monitoring wells & soil stockpiles
fl Location & depth of all samples taken
fl Buildings, fences, & property boundaries
n Utility conduits (sewers, gas, water, storm
drains, electrical etc.)
fI Depth to groundwater (ifencountered)
SAMPLE INFORMATION TABLE (Closure Notice)
Analysis method(s)'Sample #tLa,blD
8015b,8260bss-l@ 12.s'
8015b,8260bss-2@ 13',
Unified soil classification
sarvrp ^)Complete table for all samples that were taken for closure. Sample ID numbers on the table must be consistent
with the sample ID numbers given on the site plat and in the lab analysis report.
State Certified Laboratory used: American West Analvtical Laboratories
Address 463 West 3600 South city Salt Lake citv State UT Zip 84115
Contact person Pat Noteboom Phone # f 801 ) 263-8686
Please explain any unusual or extenuating circumstances encountered during the site assessment or closure:
This 25.000 eallon tank was in sreat shape. No holes or rust were visible. The walls were 5/16 inch thick. The tank was
relined in 1997 and had cathodic protection. This tank was located at the old McKay -Dee Hosoital at 3939 Harrison
I certify under penalty of law that I am the Owner of the tank(s) described above and that I am familiar with the
information on this form and that it is true, accurate and complete and further, that the procedures described
herein were followed during tan
Signature of UST Owner
Full name of Owner
Return completed Closure Notice-form, Facility Site Plat and Sample lnformation Table, Soil/Groundwater sample lab
analysis results, USC sample results, and Chain of Custody form within 90 days of UST Closure to:
2
J
4
State of Utah Dept. of Environmental Quality
Division of Enviionmental Response and Remediation UST Section
P.O. Box 144840
168 North 1950 West
Salt Lake Ciry, Utah 84114-4840
a
Contact Chris Nolan
Analyzod: August 31,2002
USC
AMERICAN
WEST
ANALYTICAL
LABORATORIES
163 West 3600 South
Salt Lake City. Utah
841 l5
ANALYTICAL REPORT
Client Industial Health Incorporated
Collected: August 29, 2002
Received: August 30, 2002
AnalysisRequested: USC
Lab Sample D: L52204-02A
Field Sample ID: SS-1 USC-I
Site ID: McKay-Dee /028-7050
Result
Uniform Soil Classification CL:Lean Clay
(80 r ) 263-8686
I Free [phone]
Fax [phone]
.ri I : au'[e-mail]
Kyle F. Gross
Laboratory Director
Peggy McNicol
QA Officer
Reteased rt, _A l.- %. _
Laboratory Supervisor Report Date:September 11,2002
Page I of 5
A
-163 West 3600 South
-
ORGANIC ANALYSIS REPORT
Client Industial Health lncorporated Contact Chris Nolan
AMERICAN Collected: August 29,2002 Analyzed: August 31,2002
*EST Received: August 30,2002 Exbacted: August 30,2002
ANALYTICAL
LAB6RAT9RTES Analysis Requested: TPH by SW8015B
Lab Sample E: L52204-01B
Field Sample ID: SS-1 @ 12.5'
Site ID: McKay-Dee I 02E-7050
Salt Lake City, Utah Analytical Results TPH-DRO by 80158/3545
84115 Units = mg&gdry
Final Dilution Factor: I
Comlnund
Surr: 4-Bromofl uorobenzene
( 80 I ) 263-8686 Total Petroleum Hydrocarbon (DRO)
Free [phone]
Fax [phone]
, i I : arr alr?Ijxmission.com
Kyle F. Gross
Laboratory Director
Peggy McNicol
QA Officer
%o Moisture: 18
Reporting Analytical
Iimit Result
lG97 32.4 Yo
20 <20
Releasedby, W
Laboratory Supervisor ReportDate: September ll,2}Oz
Page 2 of 5
-
ORGANIC ANALYSIS REPORT
Client Industial Health Incorporated Contact Chris Nolan
AMERICAN Collected: August 29,2002 Analprd: August 31,2002
*EST Received: August 30,2002 Exfracted: August 30,2002
ANALYTICAL
LABORATORTES Analysis Requested: TPH by SW8015B
Lab Sample D: L52204-038
Field Sample ID: SS-2 @ 13'
Site ID: McKay-Dee I 028-7050
163 West 3600 South
Salt Lake City, Utah Analytical Results TPH-DRO by 80158/3545
84115 Units = mg/kg-dry
FinalDilutionFactor: I
Compound
Surr: 4-Bromofl uorobenzene
(801 ) 263-8686 Total Petroleum Hydrocarbon (DRo)
Free [phone]
Fax [phone]
il: [e-mail]
Kyle F. Gross
Laboratory Director
Peggy McNicol
QA Officer
Released by:
%o Moisture: 19
Reporting Analytical
Limit Result
lG97 30.7 Yo
20 <20
@
Laboratory Supervisor Report Date: Septernber 11,2002
Page 3 of 5
1rt is provided for rhe exctusive use of the addressee. Privileges of subsequent use of the name of this company or anv ,"rn*::]5:j:Il .1,^:?11.,:111:jl::i:.*ir::fl::i
Client Indusrial Health Incorporated
Collected: August 29, 2002
Received: August 30,2002
Analysis Requested: SW8260B/5030A
Lab Sample ID: L52204-01A
Field Sample ID: SS-1 @ 12.5'
Site ID: McKay-Dee I 028-7050
Analytical Results
Contact: Chris Nolan
Anallzrd: September 10, 2002
8260-S-MBTEXI\
1
AMERICAN
WEST
ANALYTICAL
LABORATORIES
-163 West 3600 South
Salt Lake City, Utah
841 l5 UniB= mglkg-dry
Final Dilution Factor 2.56
Compound
Surr: 1,2-Dichloroethane-d4
Surr: 4-Bromofl uorobenzene
Surr: Dibrom ofl uoromethane
Surr: Toluene-d8
Benzene
Toluene
Ethylbenzene
Xylene, Total
Naphthalene
7o Moisture: 18
Reporting furalytical
Iimit Result
(80r) 263-8686
Free [phone]
Fax [phone]
r I : as [e-mail]
Kyle F. Gross
Laboratory Director
Peggy McNicol
QA Officer
65-134
7G134
80-120
&tll5
0.0026
0.0051
0.0051
0.0051
0.0051
104 Vo
96.3 o/"
105 Vo
103 o/"
< 0.0026
< 0.0051
< 0.0051
< 0.0051
< 0.0051
Rereased ar -q /f
?a *- ,
Laboratory Supervisor Report Date:September 11,2002
Page 4 of 5
Client lndusrial Health lncorporated
Collected: August 29,2002
Received: August 30, 2002
Analysis Requested: SW8260B/5030A
Lab Sample ID: L52204-034
Field Sample ID: SS-2 @ 13'
Site ID: McKay-Dee l02E-7050
Analytical Results
Contact: Chris Nolan
Analyzed: September 10,2002
826O.S.MBTEXN
ORGANIC ANALYSIS REPORT
AMERICAN
WEST
ANALYTICAL
LABORATORIES
l6i West 3600 South
Salt Lake City, Utah
841 l5 Units= mdkg-dry
Final Dilution Factor
Compound
2.54
7o Moisture: 19
Reporting Analytical
Limit Result
(80r) 263-8686
i Free [phone]
Fax [phone]
.iil : au [e-mail]
Kyle F. Gross
Laboratory Director
Peggy McNicol
QA Officer
Sun: 1,2-Dichloroethane-d4
Surr: 4-Bromofl uorobenzene
Surr: Dibromofl uoromethane
Sun: Toluene-d8
Benzene
Toluene
Ethylbenzene
Xylene, Total
Naphthalene
65-134
7Ur34
80-120
8+115
0.0025
0.0051
0.0051
0.0051
0.0051
103 o/o
93.8 o/o
104 0h
104 o/o
< 0.0025
< 0.0051
< 0.0051
< 0.0051
< 0.0051
Released ty: OU!. /aZ: ot = _
Laboratory Supervisor Report Date:September 11,2002
Page 5 of 5
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Underground Storage Tank Closure Report
Former McKay-Dee Hospital
3939 Harrison Boulevard
Ogden, Utah
On August 29,2002, one 25,000-gallon underground storage tank (UST) and associated piping were
removed from the east side of the Engineering Building at the former McKay-Dee Hospital, located at
3939 Harrison Boulevard, Ogden, Utah. The tank was removed as part of the demolition activities at the
hospital, which has been replaced by a new medical facility located at 4401Harrison Boulevard., Ogden,
Utah.
Tank System Description
The diesel fuel storage tank was constructed of single-wall steel and had a holding capacity of 25,000
gallons. Copper product lines and retum lines connected the tank to the boilers located in the basement
of the adjacent Engineering Building. The tank, installed in 1969, was upgraded in 1997 to add cathodic
protection and new lining. The enclosed site map shows the location of the UST, associated piping, and
soil sample locations.
Tank Removal Activities
An Underground Storage Tank Closure Plan was submitted by IHI Environmental (IHI) to the UST
Section of the Utah Department of Environmental Quality, Division of Environmental Response and
Remediation (DERR). Mr. Ray Bakker of the Weber Morgan Health Department was present during
tank cleaning and removal.
The tank was excavated and removed by T W Company. A total of 600 gallons of residual product, 50
gallons of rinsate, and 30 gallons of sludge was removed from the tank by National Tank and
Monitoring during the tank cleaning. The tank was cleaned by rinsing with a high-pressure water spray.
The product, sludge, and rinsate were transported off site by National Tank and Monitoring for
separation and treatment at their facility. The tank was brought to Durbano Metals, 2904Pacifrc
Avenue, Ogden, Utah.
Site Assessment and Sampling
A visual inspection indicated the tank and associated piping were in good condition. No cracks, rust,
pitting or holes were observed in the 5/16-inch-thick steel tank. Soils excavated from around the sides
and bottoms of the tanks were screened by Chris Nolan of IHI Environmental (IHI), Salt Lake City,
Utah, with an organic vapor monitor (Environmental Instruments' photoionization detector), calibrated
at the site according to the manufacturer's instructions. No positive readings were obtained from the
excavated soils.
The tank sat on a concrete cradle that contained tie-downs. Due to ongoing cave-in of the excavation
sidewalls, the concrete cradle was not removed.
Two soil samples were collected to document conditions at the time of closure, as per the approved
closure plan. Soil samples (SS-1 and SS-2) were collected from the tank excavation at either end of the
tank, approximately one foot below the bottom of the tank, adjacent to the concrete cradle.
IHCHS,Inc.
McKay-Dee Tank Closure Report
IHI Environmental
Project # 028-7050
All closure samples were collected according to Utah DERR UST Regulations R311-205. Mr. Nolan
(Utah Certificate GS-l l0i) conducted the closure sampling. Sample locations are shown on the Site
Plan.
Soil samples were collected from the back-hoe bucket. They were packed tightly into laboratory-
supplied four-ounce glass jars and sealed with Teflon-lined lids. Sample containers were labeled and
immediately placed in an iced cooler until delivery to the analytical laboratory the next day. A chain-of-
custody record was prepared in the field and kept with the samples at all times.
The samples were analyzed for total petroleum hydrocarbons diesel range organics (TPH-DRO) by
Method 80158, and for benzene, toluene, ethyl benzene, xylenes and naphthalene (BTEXN) by EPA
Method 82608. All analyses were performed by American West Analytical Laboratories of Salt Lake
City, a Utah state-certified laboratory.
The soil sample SS-1 was analyzed according to the Unified Soil Classification System (USC), using
Method 2488-84. The analytical laboratory classified the USC sample as lean clay (CL).
The results of the closure sampling analyses are presented in Table 1. No analyes were reported above
method detection limit.
Table I
Summary of Soil Analytical Results
Former McKay-Dee UST
(results are in parts per million)
Sample
ID
Sample Total Naph-
thalene
TPH
DRO
Ethyl-
Benzene Toluene benzene
SS-1
SS-2
Tier 1*
t2.5
13
0.3
< 0.003 < 0.005
< 0.003 < 0.005
0.9 6l
< 0.005
< 0.005
23
Xvlenes
< 0.005
< 0.005
235
< 0.005
< 0.005
10
<20
<20
1s00.
* RBCA Tier I Screening Levels Established by DERR
Benzene, toluene, ethyl benzene, xylenes, and naphthalene analyzed by Method 82608. Total petroleum hydrocarbons
diesel range organics analyzed by Method 80158.
Visual observations made of the excavated soil and the tank at the time of removal, and the analytical
results of closure sampling indicate that no release has occurred at this site. No additional work is
required at this location.
IHCHS, inc.
McKay-Dee Tank Closure Report
IHI Environmental
Project # 028-7050
-. .UTA}I U$T.PHOGRAM . acility lD t*o, i)
Permanent Closure I
1., Ownerehin oi.T,ll",Looatlon of T
Owner Name 7-
-Y"- s-t,'s Sfur S
- ?^',*
= ,S!.c, ""'" urr ,w#:
-
Area Code
State
(check the best description of land use)
Other
Facility Name
-Street
Address i
2.Type (Steet, FRp,
5.,!o* closed (Flmvd, inplace,
Cert. #: GS // 0 I
O F Expiration Date:
of closure plan is on Site:
2. Product removed: y N
3. Sludge removed; y N Bv: ./
4. Tanks cleaned: y N By: t/Rinsate disposed at: y)
Cleaned, secured in place, and
7. Tank disposal site:
PID or FID meter readings (indicate location on the site plat.):
--Gain or span:- calibration specs:
1. Soil contamination is evident:Depthof contamination: 0-3 feet
2. Water contamination is evident:Pgpl!to water taotei)t ,)Slope direction of surface
3. # of samples collected: _Z€W _ Soit / USC 4. Certified Lab:
lndicate location and depth of samples on the site plat.
and submitted them to the State Lab for
8. Contaminated soil overexcavated: y N N/A
Cert# Date: 8- Z-7.-"rr-Distribution: Wnite-Oenn,@
Bevised 5/98
--\
, :.I .,"'r ..J.8 P,ffi.ff,ft:,,,r,
Ferrnanent Closure lnspectit f #:iBl ib
Fasiffi=Sle,Flal
NORTH
;q
t$
Show locations ol all buildings, streets, tanks, piping and dispenser islands. lndjcate localion and depth of all samples collected by the sampler and the inspector
Also indicate the location of anv reDorted PID or FID readinos
\
;\
%;>
Fo, t nl;R tb.rsi,'lnd,,t t$,thp-clfstati6e#,p' 4.{,ffiffilo,tharfe-ercst:
Residences I DCrO Commercial Buildings -,/Property Line 6e,Active Water Well
Surface Water Sewer Line Water Line Natural Gas Line
Telephone Line I Electrical Line Storm Drain Other:
Comments:
l(name).J.4,E,'certifythatlinspectedtheabove-namedfacilityon(date):q-
tnspector's signature:r '' llil ,---? ," '-_.oate: if-a6 z a) LzCert#
(Hliirtd :iri.
White-DERFl, Yellow-lnspector,rev0201 .wpd
12000rl 0
HEALTII DEPARTMEilTJUIy 17, 2002
2570 GrantAvenue
Ogden,Uah 84401
f80rl 399€433
F/D( l80rl 399€306
EVAN NELSON, MD, MPH, MS
Health Officer
DMsion Directors
CRAG HENINGER. Administration
CHUDA PRICE. Nuring
JOE DECARIA Environmental Health
KMN IHOMPSON. Healh ftomotron
HECffii\,JLm
JUL I e 2002
DEO
EnYironmental nesporse S Rernr:iiailon
IHC Health Services lnc.
36 S State St, 23d Floor
Salt Lake City, UT 84111
RE: Closure Plan approval for Underground Storage Tanks (USTs) at
3939 Harrison Blvd, Ogden, UT
Facility ldentification No. 1200090
-
Dear Mr. Anderson:
The Closure Plan for the above-referenced facility, received by the Weber-Morgan
District Health Department on July 17, 2002, has been approved subject to the
noted modifications, if any. This department and the local fire department must be
notified 72 hours before beginning closure activities.
Our records indicate that your proposed tank remover certification expires within
three months. Please ensure that your certified remover has a valid certificate
during closure activities.
Any proposed change to the approved Closure Plan must be submitted in writing
and approved by our office before implementation. lf contamination is suspected
or found during closure activities, you must report it to the Division of
Environmental Response and Remediation (DERR) at (801) 5364100 within 24
hours of discovery.
Enclosed is a copy of the Closure Notice form which must be completed and
submitted to the Executive Secretary (UST). Please submit the environmental and
Unified Soil Classification (USC) sample analysis data and Chain of Custodyforms
with the Closure Notice as soon as possible, but no later than 90 days after tank
closure.
lf you have any questions please contact Ray Bakker at the Weber-Morgan
District Health Department at 399-8381.
X#:%
Division of Environmental Health
Gary Harris - Division of Environmental Response and Remediation
Chris Nolan - IHC Environmental, 640 E Wilmington Ave, SLC, 84100
Cc:
v I / LO/ VZ rr: rO rAn.
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IINDERGROUIID STORAGE TANK CLOSIJRE pr.AN (rev.0U0U97)['ACrLrTy rD #__ 12qQ020_
LEDUSEOIYLY
Date Received
Reviewer
Date LIID Approved
Date Mailed to State
closure Plan prepared at the request of the owaer/operator (identificd below) by chris Nolanof(coryarynamc) IltrEnvirommental phmc #(.gol)46azzzlAddress 640 East wilmingtonAvenue city salt [ake citv statc uT Zp g4106
A Contractor may prcpare this Closure Plau as the owner/operator's agetrt In preparing tte Closure plao, the Conhastor ur,"t act with
the owner/operator's knowledge aad approval. The owner/operator must sign the Ctosire ptau.
This Closure Plau is submitted in compliangs with the requirements contained h R3l l-202 Subpart G and R31l-2M (U.AC.)
T.ACILITY INT'ORMATION
Trnk Owoer IHC H*l& Serri*r Inc.fta IHC Hoqpi # ( BOt\ 442-3987
[] soleproprictonhip t lpartrership [ ] corporation
Ad&ess 36 S. State Stect23dFtmr. City state uI zip Mllt
FrcilityNue
Ad&ess 3939l{arrison Blvd crty oEden statc uT Zip g4403
Contact person Mr. Scott Anderson phonc I r 801 ) 38?-s403
Total nrrlbc of regulated uadcrgroud taots at 6is site:_Z_
Total number of regulated underground r?nLs at this sitc 1qfu closed: I
TATIKS TO BE CI,OSEI)
For waste oll tanks: Have degreasing or otbcr gryes of solvenb bccn storcd or mixed with thc waste oil?
Yes (identiff trho*) knonnr_
Aaalysis for lsad or othsr contamioants nray be requirod prior to diqpcal of cqntaniDatcd soil or other material. (Cteck with your
disposal facility.)
STAIEUSEOM,Y
the spccific substance storcd in cach tank to beEia
07 / L6/OZ
.rr
r ao, tAA 6u1DJ64:t4Z UbU UBKK
TANK REMO\aER Name Read Amold cerr # TR 0305 E:rp. Datc_LQlll/92__
Coryany Natioual Tank & Monitorine Phone # ( 801 ) 280-332a
Address 8370 South 4152 west City west lordan sate_ln zrp_!408E .
SOIUGROUITDW.dTER SA]VIPLER Name Chric Nnlan len #GS t l0l Exp.Date_215fi4-
Coapany IHI Environmeual phone # (.801\ 466-2223
Address 640 East Wilmineton Avenue CiU Salt Lakc Citv Statc UT Zip Ml06
Before the closure phn is submltted for approval, the local herlth and fire departneuts where the facility is located must be
contacted. If thefacility ts in Beavcr, Carbon, Enery, Garfield, Grud, Iron, Kane, Salt Lalcc, San,han, Yosud, or W'ashhgton cowtty contact
DERR (U$) at (801)5361100 instead oftlw local hcalth d*trlct. Yott slill must contact thc local fire deoarnunt kthese anlrrlties.
COI{TACT LOCAL HEALTH ITISTRICT Name of Dist. ''lYeber-Morgan Health Deoart DsE_@\Nl__
Contact Rav Baker Title NA Phone #( 801 'r 399-8381
CONTACTLOCALHREDEPT. Namc ofDept. Osd€nFir€D€partpr€nt Dat6lz,glm
Contact Matt Swank Title Fire Marsbal Phone # LE0IJ529:E@
DISPOSAL INFORT{ATTON
TanK$ will bc disposcd at Facility Athc.Steel
Addrcss 4221 Wcst700 Soum City Saltlake C tartr W :Zip 84104-
Contactpsson John Soiesel Phoac #( 801)972-96619
Product lines will either be: X removed or
-
clcaned secnred in placc, and capped.
Vent lines will either b€: X removed or _ cleancd and sccured open.
Piping will be disposed at Facility,Afi-AS STBFT,
Addrcss 4221 West 700 South City Salt take City SUrc UT Ap 84104
Contact #LE0t\92-9669
Tank(s) will be empfied by: company Natioad Tark & Moaitoring Phorc # ( 801 ) 280-3324
Tank(s) will be cleaned by coryany Nationd Tank & Monitoring Phone # (,801). 280:3324
Contemlneted water ln the tenk/rinsatc will bc disposcd at facility National Tank & Monitorine
Contactperson Grcq Kehl Phoac #r ROl 'r 2RG?324
Tank(s) will bc: purged or-furendered inert by the followiag me'&od: DRY ICE
Residual rludges will bc disposed at the following facility: National Tank and Monitoriug
Address 4152$Icst 8370 South City- Wcst Iortu Stac Uf Zip 8a088
Contactperson GrosKehl Phouc#/ mr \ rnn-l??r'
FOR CLOSI'RE IN-PI,ACE ONLY
[ ] Facility Sitc Plat, Saryle Information Table, sauple resulb and Chain of Costody foros are inclu&d
[ ] Approval for in-place closrue has bee,n granfd by &c Local Firc Dcpartmeot
Fire Dept. Phouc #J-lqlJ----cotrtact Datc-
[ ] Approval for in'placc closue has been granted by thc Local Hcalth Dqarment
HealthDistrict-Phouc #l!0ll__Contact Datr
[ ] Substaace to be used to fill ta*s
All materials generated from UST closues must be nunaged aad disposed rtr a mrnner 16a1 does not placc thosc matcriats in dircct
contact with the euvhonxoed' On-sitestockpiling of contaniuaEd soils may be required prior to any soit mnnage6ent activities. lzy
person providingremedial assisancefor afee, including a*ation and oyq-qcavition lifmorethan 50 yd), iutbe a C*rtifid
UST Corcultant.
Contamiuabd soils geuerated as pafi of tank rcmoyal are to be disposcd at thc following facility:
ET Technoloeies Address 6030 West 1300 South City,Satt l^ake Citv
State UT Zip 84104 Couactpersou TedSormsnburq Phone #( 801 ) 923-2065
STTE ASSESSMENT
A site essessment must be performed for all UST closures and changein-servlce. Site assessments must be perfomed rs
outlined itr R311-202, Part280.72 rnd Rtll-205 (U.AC.). If contaminstion is susDected. additionel samples must be collectrd
rt the location where contemlnedon is most Hkely to be Dresenl If sroundwrter fu encourtered. a soil sample must be
collected. in the unsatunted z.one in addidon to eech qroundwater srnple. Soil and groundwater samples Eust bc enellzed
for the compounds showl ln the followlng teble, ucing eppropriete lab methods.
SUBSTANCE CONTAMINANT COMPOIJNDS IO BE A}{ALYAD ANALYIICAL METHODS'
soL GROIJNDWATER,
orSURIACESTATER
Gasolinc ToEl Pctoleum Hydroccboos (I?H)
Bcozcnc, Tolucne, Ebrylbcrzcoe, Xyleacs @TEX), rsd MTBE
8015ModifiduE
EPA 8020 or E2l0
E0l5 Modifcd3g!
EPA602 or62
Diescl Totrl Pcnoleum HyiL,oca6oru CIPIO
Bcnzmc, Toluenc, Efhyl benzcnc, Xyle'nes, Nrphthelene (BTEOI)
8015 Modificd rg1l
EPA t020 or 8240
8015 nrodified egd
EPA602or624
Uscd Oil Oil rnd Grusc (06) or Totd Rcoovrrablc Hydrccaftou QBII)
Bcozcne, Tolucoc, Ethyl bcnzanc, Xylcnes, Nrphhalcne @TEJ{N) od
MTBE, thlogenated Volatile Orgmic Co,npoundr (VOC'a)
EPA4l3.t r4lt.I;
3sd BPA t020 or 824{)
gg! EPA 8010 or 82tO
EPA4l3.l q4l8.t
s[EFA602or624
AtrEl EPA 601 or 62{
NcwOil Oil aod &asc (O&c)cToul Recov€rablc Hydrocatmr gRlI)EPA 413.1 or4l8.l EPA4l3.l u41t.l
Other or
Unlnown
Total Potsolcum Hydrocsbou CIPTD
Bcnzcoe, Tolucac, Ettyl bcrucnc, Xylcncs, Naphlhrlcoc @TE){N)
Helogrneed Volatile Organic Cornpounds ryOes)
Or otbcr EFA nrthods o approvcd by thc Exccutivc Seoctary
E0l5 Modificd
$d EPA 8020 or 8240
lg! EPA 8010 or 8240
E0l5 modified
rod EPA602r624
aod EPA 501 or 624
Complete the Facility Slte PIet and Srmple Infonnsfion Tablc on pages 4 and 5 to provide site assessment iuformetion
CONTAMINATION INI'ORMATION
If coutaminatiou at the facility is suspccted or confirmcd. the iuforoation must be rcported to the Executive Secreary OST) at (801)
5364100within24hours. TheDivisionofWatcrQualitymrstbenotifedat(8Ol)538-6146ifFreeProductisencomtcredorif
surface water has beeu impacted. If coatamination is confrmd any person assisting in the remediation proccss for a fee must be a
Ccrtified UST Consultatrt
lAlternativcmethodsallowedfor413.l are1664or662O(b),and418.1 mayalsouseS62o(fl. NotethstanalytbalmEthodnumberrcan
change or b€ replsced le'9. 824o can be replaced by 82601. Check with rhe DERR, your certified sampler, or your analydcal laboratory i, you
have questions.
vl/Lo/uz .l,l:1, fAA oula.ro{z{lz
X = Srylclocatims(SS#,Ws+,UsC4)
Y - Monioring -Wclls(MWA)
O - Soilboriug(SB#),oGcopbcBcing(GP+)o - lYatcr Welle (doncstic, livcstock, ctc.)
Slopc of Surfacc Topogrqhy: (N, N!y, W, SW, S, SE, E, NB)
I.andUse At Site: _ Rcsidcntial_X_C,oamctcial_ Industrisl
Snrrouadiag Lad: _ Rcsidcotial _X_ Cmcrcial lldustrid
Sltc Plrt Murt InaFdcApprorlnetc Locedour Of:
n Currcot & fonoshkc, flping &disp€o8crs
E Locsiioo of all sqryleto bc takco
fI Buildings, ftuccs, &propcrtyboundaics
fI Utility conduite (aewcrs, SBs, wair, shrm
draine, clectricrl ctc.)
ig vvr
The site plat mwt bc drawu to an appropriate idmtifid scale. It mrt sbow plaaned EsDrlrling locations, substaoccs stored in anks,
and otbcr rclevaot ioforuntion Taot and saoplc identification numbers must bc cotrsisttst wiih thc infomation givcn on p. I and 5
of the Closure Plan,
Facility ID # 1200090 Drawn By Ctnis Nolan Date 6120/02
corylac bble for all car,plcs to bc r"kqr for closrc.
SAMPLB NFORMATION TABLB
fI
NORIII
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IHIS!JIR[N6{IH- Fo<:1-801-465-9616
I
FACILITY DEyEtoP-J
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E ooz
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iffrcAt fd to ;tqroaiu b b v&U, o,f tr atx_-_:llJoc,r
Rcfiood1rcrd;rEr[orffi
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,t
t(ElJ.@tflt-
PIE rc oFlrb ry uand crrE+ht ciruufrEg aoctd nfChf Or riu urca rebnlr:
aqh h r '(-6O lilo. di:rar .tft uri *" lure.Fo's ?EEtdm. Ir vra E-.!dcil ltiogdl h ltlr. It lr t i', ,F ,-t .d b.dro r
t .trd0 Edr Dclrl0 dh, O.l Iltu ltc rrur0rrrtor d thr rruXr) rrftr:octd rbwe rud tbrt I ro frdrr rit th
ht*udblIt&f*lrdihtLLtu+rr:rrbalded.b!rtct[iltrl,lt ttbplocrdEr!dr:ttdfrr&;trbl
fr[crrdiulqf irrf
Sfrturof llltwrq
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rr3lcrrnllctrlE de2 H hhr tr bHtllrhdf, roll
UNDERGROUND STORAGE TAIIK CLOSIIRE PLAN (rev. 01/01/97)FACTLTTY rD #_!200090__
LHD USE O]\LY
Date Received
Reviewer
Date LHD Approved
Date Mailed to State
Closure Plan prepared at the request of the owner/operator (identified below) by Chris Nolan
of (company name) IHI Environmental Phone # (.801\ 466-2223
Address 640 East Wilminston Avenue .City Salt Lake Citv State-lll -Zip--E4.105-
A Contractor may prepare this Closure Plan as the owner/operator's agent. In preparing the Closure Plan, the Contractor must act with
the owner/operator's knowledge and approval. The owner/operator must sign the Closure Plan.
This Closure Plan is submitted in compliance with the requirements contained in R31 l-202 Subpart G and R311-204 (U.A.C.)
FACILITY INFORMATION
Tank Owner IHC Health Services I hone # (.801\ 442-3987
[] soleproprietorship [ ]parurership [ ] corporation
Address 36 S. State Street 23'd Floor. City State UT Zip-84.1L1-
Facility Name McKav-Dee Hospital (oldon4
Address 3939 Harrison Blvd City Ogden State UT Zip-844Q3-
Contact person Mr. Scott Anderson Phone # ( 801 ) 387-5403
Total number of regulated underground tanks at this site: 2
Total number of regulated underground tanks at this site to be closed: 1
TANKS TO BE CLOSED
Tank #I
Date Installed 1969
Capacity 25,000 gal
Substance stored'Diesel
Date last operated Current
* Indicate the specific substance stored in each tank to be closed (regular, unleaded, diesel, waste oil, etc.)
For waste oil tanks: Have degreasing or other types of solvents been stored or mixed with the waste oil?
Yes (identify if known) NA No-}lot known-
Analysis for lead or other contaminants may be required prior to disposal of contaminated soil or other material. (Check with your
disposal facility.)
SLC
ST.A.TE USE OI\LY
Date Received From LHD
TANK REMOVER Name Read Arnold Cer. IR 0305 Exp.Date 10115102
Company National Tank & Monito hone # ( 801 ) 280-3324
Address 8370 South 4152 West City West.Iordan State UT Zip 84088
SOIL/GROUNDWATERSAMPLER Name ChrisNolan Cert.#GS l10l Exp.Date 2ll5l04
Company IHI Environmental Phone # (.801). 466-2223
Address 640 East Wilminston Avenue salr T.ake Citu State UT Zio 84106
Before the closure plan is submitted for approval, the local health and lire departments where the facility is located must be
contacted. If thefacility is in Beaver, Carbon, Emery, Garfield, Grand, Iron, Kane, Salt Lake, San Juan, lYasatch, or lYashington county contact
DERR(UST)at (801)536-4l00insteadofthelocalhealthdistrict. Youstillmustcontactthelocalfiredepartmentinthesecounties.
CONTACTLOCALHEALTHDISTRICT NameofDist. Weber-MorganHealthDepart. Date 6120102
Contact Ray Baker Title NA Phone # ( 801 ) 399-8381
CONTACT LOCAL FIRE DEPT. Name of Dept. Ogden Fire Departrnent Date 6120102
Contact Matt Swank Title Fire Marshal Phone # ( 801 ) 629-8070
DISPOSAL INFORMATION
Tank(s) will be disposed at: Facility
City
Atlns Steel
Address 4221West 700 South City Salt Lake Citv State UT Zip 84104
Contactperson John SDieeel Phone # (,801\972-9669
Product lines will either be: X removed or cleaned, secured in place, and capped.
Ventlineswilleitherbe:Xremovedor-cleanedandsecuredopen.
Piping will be disposed at: Facility ATI,AS STEEL
Address 4221 West 700 South city salt Lake citv State UT Zip 84104
Contactperson John Spiegel Phone # (.801)972-9669
Tank(s) will be emptied by: company National Tank & Moni hone # ( 801 ) 280-3324
Tank(s) will be cleaned by: company National Tank & Monit hone # ( 801 ) 280-3324
Contaminated water in the tank/rinsate will be disposed at: Facility,Nafional Tank & Monitorrns
Contact person Greg Kehl Phone #( 801 ) 280-3324
Tank(s) will be:-purged or-l-rendered inert by the following method:DRY TCE
Residual sludges will be disposed at the following facility:National Tank and Monitorine
Address 4152West 8370 South CitV West Jordan State UT Zip 84088
Contact Derson Gres Kehl Phone #r 801 \ 280-7124
FOR CLOST]RE IN-PLACE ONLY
t ] Facility Site Plat, Sample Information Table, sample results and Chain of Custody forms are included.
t I Approval for in-place closure has been granted by the Local Fire Departrnent.
Fire Dept. Phone # ( 801 ) Contact Date-
t ] Approval for in-place closure has been granted by the Local Health Departrnent.
Health District Phone # ( 801 ) Contact Date-
[ ] Substance to be used to fill tanks
CONTAMINATED MATERIAI ruST BE DISPOSED AT AN ACCEPTAB
All materials generated from UST closures must be managed and disposed in a manner that does not place those materials in direct
contact with the environment. On-site stockpiling of contaminated soils may be required prior to any soil management activities. Any
person providing remedial assistance for a fee, including aeration and over-excavation (of more than 50 yd), must be a Certified
UST Consultant.
Contaminated soils generated as part of tank removal are to be disposed at the following facility:
ET Technologies Address 6030 West 1300 South City
State UT Zip_E4.1llt-Contact person Ted Sonnenburg Phone # ( 801 ) 973-2065
SITE ASSESSMENT
A site assessment must be performed for all UST closures and change-in-service. Site assessments must be performed as
outlined in R3ll-202,pari280.72 and R311-205 (U.A.C.). If contamination is suspected. additional samnles must be collected
at the location where contamination is most likely to be present. If groundwater is encountered. a soil samPle must be
collecled. in the unsaturated zone. in addition to each sroundwater sample- Soil and groundwater samples must be analyzed
for the compounds shown in the following table, using appropriate lab methods.
SUBSTANCE CONTAMINANT COMPOUNDS TO BE ANALYZED ANALYTICALMETHODS '
SOIL GROUNDWATER
or SUMACE WATER
Gasoline Total Petroleum Hydrocarbons (TPH)
Benzene, Toluene, Ethy'lbenzene, Xylenes (BTEX), and MTBE
8015 Modified and
EPA 8020 or 8240
8015 Modified g41!
EPA 602 or 624
Diesel Total Petroleum Hydrocarbons (TPH)
Benzene, Toluene, Ethyl benzene, Xylenes, Naphthalene (BTEXN)
8015 Modified g41!
EPA 8020 or 8240
8015 modified and
EPA602 or 624
Used Oil Oil and Grease (O&G) or Total Recoverable Hydrocarbons (TRH)
Benzene, Toluene, Ethyl benzene, Xylenes, Naphthalene @TE)C,I) and
MTBE, Halogenated Volatile Organic Compounds (VOC's)
EPA413.l or4l8.1;
and EPA 8020 or 8240
and EPA 8010 or 8240
EPA413.1 or418.1
and EPA 602 or 624
and EPA 601 or 624
New Oil Oil and Grease (O&G) or Total Recoverable Hydrocarbons (TRH)EPA413.1 or418.1 EPA4l3.l or4l8.1
Other or
Unknown
Total Petroleum Hydrocarbons (TPH)
Benzene, Toluene, Ethyl benzene, Xylenes, Naphthalene (BTEXI'{)
Halogenated Volatile Organic Compounds (VOC's)
Or other EPA methods as approved by the Executive Secretary
8015 Modified
and EPA 8020 or 8240
and EPA 8010 or 8240
8015 modified
and EPA 602 or 624
and EPA 601 or 624
Complete the Facility Site Plat and Sample Information Table on pages 4 and 5 to provide site assessment information.
CONTAMINATION INFORMATION
If contamination at the facility is suspected or confirmed, the information must be reported to the Executive Secretary QST) at (801)
536-4100 within 24 hours. The Division of Water Quality must be notified at [phone] if Free Product is encountered or if
surface water has been impacted. If contamination is confirmed, any person assisting in the remediatiou process for a fee must be a
Certifi ed UST Consultant.
rAlternativemethodsallowedfor413.lare1664or5520(b),and418.1 mayalsouse552O(f). Notethatanalytical methodnumberscan
change or be replaced (e.g. 8240 can be replaced by 8260). Check with the DERR, your certified sampler, or your analytical laboratory if you
have questions.
Salt Lake Citv
1
_ FACTLITY SITE PLAT (CLOSURT )AI\n
The site plat must be drawn to an appropriate identified scale. It must show planned sampling locations, substances stored in tanls,
and other relevant information. Tank and sample identification numbers must be consistent with the information given on p. I and 5
of the Closure Plan.
Facility D # 1200090 Drawn By pate 6/20102Chris Nolan
f)
NORTH
\-J
s-
.L\
5.u1"r 1,:;1Q_Feet
t-Jq
7-
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5<- | , osL-t
u
&J
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v
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Ur!)($
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\)(--
r$
(.
e\l
vI
,4-
ts
l
JJ
o
o
oa
\A
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x
ss-L
X = Sample locations (SS#, WS+, USC-#)
Y : Monitoring Wells (MW#,)
O : Soil boring (SB+), or Geoprobe Boring (GP#)
a = Water Wells (domestic, livestock, etc.)
Slope of Surface Topography: (N, NW, W, SW, S, SE, E, NE)
Land Use At Site: _ Residential _X_ Commercial _ Indusrial drains, electrical etc.)
Surrounding Land:
-
Residential
-X-
Commercial
-
Industrial
Site Plat Must Indicate Approximate Locations Of:
fI Current & former tanks, piping & dispensers
II Location of all samples to be taken
II Buildings, fences, & property boundaries
n Utility conduits (sewers, gas, water, storm
Complete table for all samples to be taken for closure.
SAMPLE INFORMATION TABLE
o8/2L/02 FRI 13:48 FAX 84\442 3178 IHC
IHI E}fJIRtltGNTfl- Fax:[phone]
FACILITY DEV\OPUENT
Jur, . ru2 15:39
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Locetion of Tanks v
yrttt?n
€,1 State UT Zto * 4
LocationOontact- SC *f Phone g^ 206
Complete for each tank. lf facillty has more ihan 4 tanks, eomplete lnformatlon lor sdditlonal tanks on geparats rorm.
Number of tanks at facility:
Tank lnstallation Date
Capacity of tank (in gallons)
Tank is in use (Y) or, if not in use, give date last used
lf not in use, depth of product in tank (in inches)
Answer the following for all tanks, Note any exceptions in the last coltrrttn.
Current year tank tags are in place
Material of construction of tanks (steel, FRP, composite, etc.)
Material of construction of piping (steel, FRP, flex plastic, etc.)
Piping type (pressure, safe/US suction, gravity, etc.)
filled by transfers of less than 25
if filled bv transfers of less than 25
FOr ovenrll alarm: Alarm ts located where it can be seen and
alarm is clearlv marked
Coffosion Protection- Answer the following lor all tanks. Note any exceptione in ths lest column.
Method used on tanks (NM, CS,
Method used on piping (NM, CS, lC, SA, NP)
Method used on flex connectors (8, CS, NC, CP, NM, NP, N/A)
Enclosed containment sumps at tanks (subpump) and dispensers
lndicate dates of upgrades- lining, tank or piping cathodic protection.
Cathodic Prolection Testing Complete lor each hnk.
6 months of installation and every 3
Tank rester Sahn Ltbr,,^ Dabq-ll'00
Flex Tester Date
of Owner or Owner's Representative present durinq inspection rl
Utah UST Prograrn
Release Detection lnspection Checklist tD/Ziilfi
\
I
N
White-DERR. Yellow-lnspector.
1 a
m McKev-DrE HosPrrAL CENren
I FIC A Service oJ Intermountain Heolth Care
September 14,2000
Paul Harding
Non-compliance of underground storage tanks at McKay-Dee Hospital.
1939 Harrison Boulcvard
P.O. Box 9170
Ogdcn, Utah 84409'0370
(801 ) 627-2800
lzo o ono
TO:
RE:
The submitted documentation shows that we have had a qualified cathodic protection
tester test the cathodic protection system on UST #l at McKay-Dee Hospital.
Documentation also submitted shows that the impressed current cathodic protection
system is inspected for operation every 60 days on UST#1 at McKay-Dee Hospital.
Jeff Montgomery
Engineering supervisor
McKay-Dee Hospital
DERR
E]MNOffi EilTTL RESPOI{SE & REilEDNil ON
ElITERED
sP25m
Michaet O. travitt :i
Govemor
ii
Dianne R. Nielson, Ph.D. ii
Executive Director
fi
Kent P. Gray ii
Director
DEPARTMENT OF ENVIRONMENTAL QUALITY
DTVISION OF ENVIRONMENTAL RESPONSE AND REMEDIATION
168 North 1950 West
P.O. Box 144840
Salt Lake City, Utah 841 l4-4840
[phone] Voice
[phone] Fax
[phone] T.D.D.
TO:
RE:
August 18, 2000
Scott Anderson
McKay Dee Hospital Center
3939 Harrison Blvd.
Ogden, UT 84409-0370
Non-compliance of underground stor:rge tanks at McKay Dee Hospital Center, 3939 Hanison Boulevard,
Ogd.:n, IJtah: Facility I D. #12C0090.
The Utah Underground Storage Tank (UST) Act provides that the Executive Secretary (UST) may revoke a
Certificate of Compliance if it is determined that a facility is not in substantial compliance with all state and federal
UST statutes, rules and regulations.
At the request of the Executive Secretary (UST), the Division of Environmental Response and Remediation (DERR)
performed a compliance review for the underground storage tanks at the above facility. The compliance review,
performed onMay25,2000,indicatesyouhavenotsatisfiedtherequirementsoftheActandareoutofcompliance.
To achieve compliance you must do the following:
l. Submit documentation to show that you have had a qualified cathodic protection tester test your
cathodic protection system within the last three years for UST #1 (25'000 gallon diesel) including
piping.
2. Submit documentation to show that the impressed current cathodic protection system is inspected
for proper operation every 60 days for UST #L.
please reiurn a copy of this speeci nremo with the above items to speed processirrg. If tite above iniormaiion is
submitted to this office by October 6,2000, and substantial compliance is achieved and maintained, no further action
will be taken on this matter. Failure to respond to this request by the date specified will initiate the revocation process
for your Certificate of Compliance. If you have questions concerning this matter or need any assistance, please
contact Paul Harding at [phone].
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Impressed Current
Cathodic Protection
Test
Prepared for:
McKay-Dee Hospital
3939 Harrison Blvd.
Ogden, Utah 84409
Utah Facility ID# 1200090
Prepared on:
September Iltr, 2000
By:
John Labrum
Precisiort'I'r'st rnq Sl recialist
I I l-+9 Sand', (itrle h l{oad
Sartclr. t I ti.-l{i!)-l
^^
John labrum
hecisiut Tating $per:ialist
I I lJ9 Sandy Gulch Rood
Sand-1,, U'f 8$9J
80t-195-2606
801-57(>9925 fttx
Impressed Current Cathodic Protection
Date: 09llYA0
Facility ID: 1200090
Mckay-Dee Hospital
3939 Harison Blvd.
Ogden,IIT 84409
Test Date: 09/08/00
Test Number: 090800-2
Operator: John Labrum
NACE #: 744
Rectifier
lvlake Universal
Model AAP
Serial # 962463
Capacrty 24112
Operating Volts 3.5
Operating Arys 3.6
Honr Meter 30982.12
Comments:
Copper product lines are protected with the irnpressed
current systenr See site rnap for negative potential
readings.
^\
Facility ID# 1200090
Test Locations
Test Location #1
Tank # I
Tank #
Tank #
Test Location #3
Tank # I
Tank #
Tank #
Test Location #5
Tank # I
Tank #
Tank #
Test Location#7
Tank # I
Tank #
Tank #
Test Location #9
Tank #
Tank #
Tank #
Test Location#2
Tank # 1
Tank #
Tank #
Test Locationtl4
Tank # I
Tank #
Tank #
Test Location #6
Tank # I
Tank #
Tank #
Test Location #8
Tank #
Tank #
Tank #
Test Location #10
Tank #
Tank #
Tank #
-1529
-1332
-1483
-t44t
-1318
-1466
-1456
lnstant Off: Tank #l Test Location #7 On -1441Off-1305
Instant Off:
Instant Off:
Instant Off:
John Labrum
hzcffion Tatiag Spedali*
I I I JQ Sunil.y' (iulch Rotl
.l'rntl.t', I' I 8J{1,)J
h'1) I -J95- )(tl)6
ll0 I -.j.6-8J6: /it-t
September I lth, 2000
McKay-Dee Hospital
3939 Harrison Blvd.
Ogdeq Utah 84409 Utah Facility ID #1200090
Impressed current cP Test, site map and test locations. This rnap n:gllo s"ale.
A = tesr l-a*rPil9 I
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arrxdtY
l. Ownership of Tank(s)ll. Location of Tank(s) /
Number
City
Area
Facility Name
l'r Mt/a-. 'W '&Vb z
County n'
Certificate ol Compliance on site? Yes No Certificate year:
Complete for each tank. ll facility has more than 4 tanks, complete information for additional tanks on separate torm.
Number ot tanks at facility:
Current year tag is displayed
ll not in use, date last used
lf not in use, depth of product in tank (in inches)
Month and year tank installed
Capacity of tank (in gallons)
Material ol construction of tank (steel, FRP, etc.)
Material of construction ol piping (steel, FBP, etc.)
Piping type (pressure, suction, gravity, etc.)
lV. Release Detectlon For Tanks rndbare the for each tank. Complete the appropriate checklist for sacfi rnethod used.
Emergency Generator tank (leak detection
Method used (enter method used and complete appropriate form)
V. Release Detectlon For Plping lndicate method(s) used and complete appropriate tank checklists where applicabte.
Method used (complete separate form where applicable)
Automatic Line Leak Detector type and model
Date of last Leak Detector perlormance test
Date ol last Line Tightness Test
Name and company of certified tester
No leak detection required (must answer'yes'to all questions below)
Operates at less than atmospheric pressure
Slope of piping allows ALL product to drain into tank when suction is released
Has only ONE check valve, located directly under pump
Above information is verifiable; use comments section below to document how it is verifiable
thatl haveinspectedtheabove-namedfacitityon 5 -LS - a X
lnspector's
h. &y, yee. dm)
Date: t- - ZS - t:>
Signature of Owner or Owner's Representative Present During lnspection:
tLoqD
UTAH UST PROGRAM
Release Detection I on Checklist
Distdbution: White-DERR, Yellow-tnspector, pink-Facility/Owner Revised Z4l99
UTAH UST PROGRAM Faclttty tDNo.D--46 €i,%
ll, Overfill, and Corrosion Protection lnspection Checklist
Please complele all inlormation tor aach tank. Use addltional lorms as necessary il the lacillty has more than 4 tanks.
SPILL/OVERFILL PREVENTION <JW fank2 Tank 3 Tank 4
The UST system is filled by translers of 25 gallons or less. lf yes, spill
and overfill prevention is not required.Yes @ Yes e Yes No Yes No
ls there a spill containment device that will prevent release of product into
the environment? lndicate type: Spill bucket <5 gal., Spill bucket >5 gal.,
Containment sump at tank fill.
<XA' No @No Yes No Yes No
ls there an over'
Ball float (in vent
ention de'tank? lndicate type
d), Autom larm, or Other @No Yes No Yes No
For overlill alarm only: ls the alarm located where it can be easily seen
and heard bv the deliverv driver? *Yes No Yes No Yes No Yes No
For overlill alarm only: ls the alarm clearly marked to indicate what is
meant when the alarm sounds?Yes No Yes No Yes No Yes No
CORROSION PHOTECTION
Tank 1 Tank 2 Tank 3 Tank 4
lndicate the lype of corrosion protection: Non-metallic (NM), Composite
steel (CS), lnternal lining (lL), lmpressed Current (lC), Sacrificial Anode
Tank
,?,TankE.E.P Tank Tank
(SA), or Not protected (NP).Piping
l"tr4tr,Piping Piping
lndicate the type of corrosion protection on Flex connectors and/or Swing
joints: Booted (B), Total containment (TC), Not in.contact with soil or
water (NC), Cathodically protected (CP), Non-metallic (NM) and Not
Protecled (NP)
Sub-Pump Sub.Pumo7_Sub.Pump Sub-Pumo
Dismnser DisFnser Disp€nser Disp€nser
Tank lining
lJ tank or piping has been
upgraded, indicate date upgrades Tank cathodic protection
were performed:
Piping cathodic protection
The results of the last two cathodic protection tests are available. (within
6 months of installation and every 3 years thereafter).Yes No Yes No Yes No Yes No
Tank. Tester Date volts volts volts volts
Pioino. Tester Date volts volts volts volts
Flex. Tester
Sub-Pumo
volts
Sub-Pump
volts
Sub-Pump
volts
Sub-Pump
volls
Dispenser
volts
DisFns6r
volts
Disp€nser
volts
Dispens€r
volts
For impressed current system: The results ol the last three equipment
operation checks are availabG. iEquip. check required every 60 days.)
yes &Yes No Yes No
(,nmmcnTs'
lnspector's Signature:Dare: 4'7€ -fre)
Siqnature of Owner or Owner's Reoresentative Present Durinq lnspection:
Dist'ibution: Wh(e-DERFl, Yellow-lnsp6for, Pink-Facility/Owner Flevised 2/4/99
UTAH UST PROGRAM Facirity ton". /ZOaaQ
Automatic Tank Gauoino
Manutacturer, name and model numbe, ot.v"t" , U€ZAZ&qCOV7 775 3d
Please clrcle Yes or No for each questlon for each tank
lf facllity haa more than 4 tanks, complcte lnlormatlon tor addltlonal tanks on soparate lom.
-fffii"tr'Tank 2 Tank 3 Tank 4
Device documentation ls available on-site (e.o.. owner's manuatl-<Q no Yes No Yes No Yes No
Records on site document that the syslem was properly lnsta[ed and callbrated
(eystem and tank setup reDort).
@*o Yes No Yes No Yes No
System is malntained in accordance wlth manufacturer's lnstructlons (records are
avallable on slte).@*'Yes No Yes No Yes No
The probe is located at the center of the tank !l no, Indlcale tllt correctlon lactor from
the tank setup rEport.
Yes' No
TIh.
Yes No
Tltt:
Yes No
TIIt:
Yes No
Tllr:
Device can measure the height of the Droduct to the nearest 118 ol an Inch fbr no Yes No Yes No Yes No
Devlce monltors the in-tank llquld levels over lhe tul! range of the tank's lnternat
height @no Yes No Yes No Yes No
A monitoring box le present and there ls evidence that the devlce ls worklng (i.e., the
device ls equlpped wlth roll ol paper lor resultg documentatlonl @; xo Yes No Yes No Yes No
Documentataon ls avallable domonsiratlng that the Automatlc Tank Gauge performed
q1alld leak tsst at least onc€ a month for the last l2 months @*o Yss No Yes No Yes No
lf no' lor whlch monthe was a valld test not performed? (specify months and year, use
space below lf necessary)
The tank wae filled to at least the mlnlmum level reguired by the manufacturer,s
equlpment protocol to enaure a valid lsak test @*o Yes No Yes No Yes No
The tank capacity ls wlthin the upper and lower slze fimlts requlred by the
manulactuter's equlpment Dtotocol lo snaurE a valld leak test @no Yes No Yes No Yes No
Have any of the leak test reports lndicated a lalled test? tf yes, spoclfy ln the space
below the month, year, and what follow-up actlons have b€en taken.
,u, @ ) Yes No Yes No Yes No
Documentation of perlormance ciaims for the automatlc lsak test feature ls available
and shows the ability to detect leaks of 0.2 gph wlth 95% or greator probablllty of
lqtection and 5oA or less probabllitv ol lalse alarm (3rd Darh, cenfflcaiionl-
9*'Yes No Yes No Yes No
lndicate month(s) of invalid or mlssing test:
lndlcate month(s) of any lailed test:
Comments:
-
lnspector's rrnn rur.,
Signatureolownero,o*n"i"n"(."""ntati,"PresentDurlnglnspec,,on,
Dlstrlbutlon: WhlteDERR, yellow-lnspcctor, plnk-Faclllty/Owner
i2,:.- 1.t f; -i
Michael O. [eavitt
Govcmor
Dianne R. Nielson, Ph.D.
Executive Director
Kent P. Gray
Director
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF ENVIRONMENTAL RESPONSE AND REMEDIATION
168 North 1950 West
P.O. Box 144840
Salt Lake City, Utah 841 14-4840
(801) 5364100 Voice
[phone] Fax
[phone] T.D.D.
TO:
August 18,2000
Scott Anderson
McKay Dee Hospital Center
3939 Hanison Blvd.
Ogden, UT 84409-0370
Non-compliance of underground storagetanks atMcKay Dee Hospital Center,3939 HarrisonBoulevard,
ogden, utah; Facility I.D. #1200090.
The Utah Underground Storage Tank (UST) Act provides that the Executive Secretary ruSD may revoke a
Certificate of Compliance if it is determined that a facility is not in substantial compliance with all state and federal
UST statutes, rules and regulations.
At the request of the Executive Secretary (UST), the Division of Environmental Response and Remediation (DERR)
performed a compliance review for the underground storage tanks at the above facility. The compliance review,
performed onMray 25,2000, indicates you have not satisfied the requirements of the Act and are out of compliance.
To achieve compliance you must do the following:
1. Submit documentation to show that you have had a qualified cathodic protection tester test your
cathodic protection system within the last three years for UST #1 (25,000 gallon diesel) including
piping.
2. Submit documentation to show that the impressed current cathodic protection system is inspected
for proper operation every 60 days for UST #1.
Please return a copy of this speed memo with the above items to speed processing. If the above information is
submitted to this office by October 6, 20(X), and substantial compliance is achieved and maintained, no funher action
will be taken on this matter. Failure to respond to this request by the date specified will initiate the revocation process
for your Certificate of Compliance. If you have questions concerning this matter or need any assistance, please
contact Paul Harding at [phone].
Fom Approvcd. OllB No. zv5{t{068.
Notification for Underground Storage Tanks
TDNUTTiBER tDOO
DATERECET\,ED 7- Zl-q 7
A. Date Entered lntoConputer
B. Data Enty Clerk hilials
C. Grrner Was Contaded b
Oarify Responses. @nrnents
_ No. ol tanks d fadlity _ tlo. ol continuation sheds anacfied
Please @ltItidLitiOB aI iters ercept :d{rn8n e'h sedim V. This lorm
rust be comdeted br eedt loCaim ontainlrg urdeqrotnd sbrago tanks" lfrue than fwe (5) tanls are owned at tis localion, photocopy the bllowirg
sheets, and staple contiruatftrn sheets !o the brm.
tb login ot ticr ahtr r.edod c hzidos re dr& Srtfoe CFCRA tGo hdir pctolm. c.g; ar,6 oloruy tratn iur[rtrlch bf$Jd a.iBnd cqldtiocofllttpglrtlr trd F.arre (GO d?rE FrMrcn
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undcryound tenls tharo.. orher ood petoleurn or taners lrlbnce6.
h b upecrd thathe inbnrurin,og p.oyiL will b. b.s.d on rEsqltuy
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,scolecriaIL
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mD'ff dedCrrbd$e!. orlocJ ggrcicof 0rc qigtce of nreigils. OrrrrlllilE-
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Wtrd Trnb tr hCudod? thderlrulnd EDtteo E d( b delin d c lny sr€acfirtrirdilt olE n s rrd(i) bus.d f Gorirl rr renrr,l*n ol naedi!.dtllblrai'.d(ariE yoflrt (ndftgqtr.odrdce.undpiping) blof qmo.i b..Edr fr.e.ornd. So.i. atrtr'e rnurCrgorrta rifie&t:
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inmotuay.
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[. LOCATTON OFTANT(S)t. owNERSHtP OFTANK(S)
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\
EPA Forlr 75lDf (fi.tr 2€2)Pags2
Michael O. Lravitt
Govcmor
Dianne R. Nielson, Ph.D.
Exeutivc Dircctor
Kent P. Gray
Dirccbr
TO: McKay-Dee Hospital
Attn: Scott Anderson
3939 Harrison Bv1d.
Ogden, UT 84409-0370
Enclos,.d is information regarding:
X Tank Notification Form
Tank Closure Plan
fank Closure Notice
Certified Tank Installers
Certified Tank Removers
Certified Tank Testers
Certified Groundwater & Soil Samplers
,,3;+.ffiit ff, ,,ll f' 6-TCm'Fg
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF E}.IVIRONMENTAL RESPONSE AND REMEDIATION
168 North 1950 West
P.O. Box 144840
Salt lake City, Utah 84114-4840
[phone] Voice
[phone] Fax
(80r) s36-4414 T.D.D.
Date:August 12, L997
From: DAVID WILSON
Fac. ID 1200090
Utatr UST Administrative Rules R3l l
Utah UST Act
EPA UST Regulations 40 CFR 280
PST Fund Information
Release/Leak Information
MUSTS for USTs
Billing Information
Certification Information kak Detection Information
For future correspondance and fuilling purlrcses, please fill out and sigz enclosed notification form. Indicateownership as facility name and address rather than the corprate office name and address.
If you have any questions, please contact me at [phone].
Sincerely,
Numberi lLoa';t?c
INSTALI,ATION INSPECTION
! Busiuessonly !Tenkonly SameesScctionl:
--
trPr"peny fl Business ooly pTank ouly
Public Agenc.v, or other entitY)
EJ, Cert#: TL.Xl {6UST INSTALLER:
Tank No. I Tank No. Tank No' Tank No' Tank l(o'
'?--1, , o "t'1. Estimated Total Capacity (gallons)
Type: FRP, Steel, ComPosite
New or Used (must be recertified)
5. Type of leak detection
!Vapor IlIonitoring
fl Tightness Test and Inventorl' Control
E lltanual Tank Guaging E Other
E GIV I\lonitoring
. Tvpe: FRI', Coated Steel. ComPosite
Type: Suction, Pressure. Graritl'
3. Ty'pe of leak detection f! .{utomatic Tank Guaging fl Tightness Test and Inventorv Control
E Ir'Ianual'fank Guaeing E Other
E GIV Irlonitoring
l. Spill device installed (T1'Pet
Overfill device installed fflPet
SPECTFICATIONS
Distance from tank(s) to nearest property line (5' minimum)
Distance from tank to nearest structure (5' plus 4f,from surface to tank)
Estimated dePth to ground$'ater
Do tanks have at least 18" spacing between tanks (stable conditions)?
If unstable walls, are tanks spaced at least 1/2 times the diameter of the tanks from each other?
can groundwater raise into the bottom of the tank excavation (must anchor)?
Does depth of instaltation conform to planned Anchoring. Surface and TraITic conditions'
groundwater conditions and piping run slope requirements?
Has I'ant< and piping Cathodic Protection systems been checked to verify they are working
Does the amount of fa
ccrtlty:itrat t' hiie luspectcd tbe above' ne med facllity on
Cert#
FACILITY SITE PLAT Facility lD No.
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Show
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ot
or any reooneo PID or FIO
of all sampres coltecteo Dy tne samorer anc, the rnripedor. Atso indicate
x.
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PotentralReceptors.lndicatediitance(inleet)tothenearest:FlesidencesBuildings>
Active water well Surlace waler
-
Other
eo,Ftr.? t A il
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certity that I inspected the above-named facility on
OS/L2/97 XON 10:50 FAI 801 ll2 lL78 If,C PACILIIT XANAGETENT E ool
_wc/cFACIUTYIDf
PETROLEI]M STOBAGE TAT{K
FINN{CTAL NESPOINITBrI.TTT I,ECL\N,ATION
Coryh0c mc fotu fr ceA lbdllty
REtrE deLla! IorE by Ilflry l, lyn
FACEITY}iIAME
FAE.ITT^DDRESS
d, *oo* to aontiurc to per.ttdpate t rr" *rt *rr, *or-I Subnlr rhis Ftuncid Rcrpousibility Dechmtim foru by Mry l, lg9l .
a subuit ore Flscal YGc lgDS Fadury Thnirrgbput Doclantim (bluc form) by lvfay I. 1997.
a All tEks including rborrcgrcrmd st(trlge trnks (AST0) Iocaod at rhis frclliry &ry bc rcquircdlo prticipdc la thc PST Tnret Hrod.
O IrdftroarrubcrofASTs,lfauy, Iocatodu&trhcility O
E r oo*. anothcrEinancirl Assu*Dcc Rcrpodblllty Mcelanirm(e)a Submit 6is Fiaanaat ncrpmsibility Dcclrration form by May l, tgg7.
O By luuc 15,lgan, snrbnnit acccPoDlc trnenc.hl ersurucc docuu;nls and $lfiD processiag fecpB Ecch,misn flJrc tbc exrct foroat rtquirod by fcdanl rcgulati@, 40 GR put 2s0,Su@t tt).
O hdicerc yur Compsry's 'Eilcrl Yead'eodlag drrc
3131 Nepa'sop Btuo ..
OGDEil, L^}, VI<09
)o-1-l
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Phone
Date
r ffi{D NO PAYrfiIiIT AT 1'EIS l:nIE r
i,iAi '' 3 1997
fNMcKAY-DEEr HCHOSPITALCENTER
3939 Honison Blvd., PO. Box 9370
Osden, Utoh 84409{370 801-627 -2800
THOMP\S E HANRAHAN, FACHE, CEO, ADMINISIRATOR
May 12,1997
Division of Environmental Response and Remediation
Underground Storage Tank Section
PO Box 144840
Salt Lake City, UT 84114-4840
Dear Sir:
SUBJECT: Declaration Forms
Enclosed find the completed Financial Responsibility Declaration and Facility Throughput
Declaration forms for McKay-Dee Hospital Center. Please send invoices to:
McKay-Dee Hospital Center
ATTN: Scott G. Anderson
3939 Harrison Blvd.
Ogden, UT 84409
If you have any questions concerning the attached forms, please contact me at [phone].
Sincerely,
><NCQO*,*
Scott G. Anderson, Director
Facility Support
Enc.: Financial ResponsibilityDeclaration
Facility Throughput Declaration
A Focility of INIERMOUNTAIN HEALTH CARE / A community hospitol system serving the lntermountoin West
Form Approvcd. OllB No. 2050{068.
Notification for Underground Storage Tanks STATET.|SEONLY
baantrlr..if.b
TDNUITBER IZOCX)1 O
TYPE OF NC'TIFICATION DArE REcErvEo 4 nn-t
fle" newFAcLnY ffi e. AMENDED I c. cr-osune
A. Oal€ Entered lnto Conputer
B. Data Enty Clerk hitials
C. Otrner Was Contacted b
Claify Responses. CdrnmenS
-/Pt!
u^// (-
_ No. of tanks at lacilty _ i.lo. ol onliruation she€ts afiach€d
INSTRTrcTIO{S
Please rype or trinr h ink aI ltenrs except lCgnatre, h seclirn V. This form
must be corpleled ror eacft loridkn corilainlng undergru.rnd sbrage tanks. lfrpre lhan five (5) tanks are ouned d tas letion, pholocopythe 6,[wing
sheets. and staple conlinuatinn sheds to the brm
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.Ihe princy pn4ce of hb notllcairn gog.un b D.b@ rd evdu.bundeqomd ada fiaae orher ored pdobum or trar&uc arbr-cca
It b_erpeaod fta0re infurmatim ynupoviai trU le Uceaon resorutty*alaHe rtods. a h theabendroiardr ncords, rorr lcrrledge. b.6el. orrccolectbn
Who lof ildfy? Sec*n &@ otRCRA.s.m.rd.4 re(phE lrd.,role.s
eremptrd, ones-ol urlrgrulnd fdrs traeOrc rquhfd s/dslrna lturst
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l. hlrn a,E L.rtd rn*s of r.r @ gaforr r ls crpciry t. d h rt irrmor trl br nocomnrrjC Frrglsilq
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Uta &6rfrnor Ar Coy..td? Ihe rntifica*ro rcquiremattE.pply D under
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hodilr:Anyonrrrto lrlrbodycrtntl&rHoltrdondrf D. f,drl.c !o. ff piry rd u oiorA $o.Oo fa.dtrrr* lorrhH adeddo b aa gftri cdrhHr hbo ffinrirrhn botal[rd.
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l-l oror fh0rod Atond specily
Vltt CEEIFTAEdiI (R.d rrd dg:r ernoafildp d rdond
l€tff mdtpeodydlilttd thawpsraralyaantrcdtdgntansarSrthehhrrdon srnrd[cdhtrbrrdC&reil&allnem+.rdfidbcedonmyfqfydltaihdrdd*Ipeila0dynopcrsDleboUffrgtlrelfiimdon! lbe[erctutlhe
sanEat irErneim b hrarrtb. ad orptoa
]{eJlrrdddJ-tlcdour
a qne'! .rthodzed npescm*r (PlnD
N'il.o@ ltfiua4t 4t4 r'22'
I Hc F*a/rvl t*rrnV,r6ua
Sfam/4*//J-?t oSagrdo/42
Prpcruort Boduabn Act }lofb.
EPA esmnales FrHc rseorfng hndm lbrt{s lorm b anerago 30 r&ubs pc response indufng tme br revi*ing hstlrcfonsr
g€0hshgandmafrtakthgltrodalaneededandconpl*rgadBufeuthgtbramSendcormmBregadngticbtrden€€0rn bb
C[de[, Hormdoo Folby Brandt Plh%, U.S. Ernfonmrital ftotecfon ng€ncy. 401 M Sfesl, Washlngilon D.C. 20460. marlted
'Afroton t}ec( Otrer h EPA'Thas brm arpnds the previous ndllcdon iorm as ginted ln 40 CFR Pst 280. Apgendt l. Prevbus
edtonsolttris ndfcdonhnn maybe ueeduhle alpples last.
EPA Forrr 75lro.l (F.tr 2€2)tudF2
lL DESCRIPTION OF UNDERGROT ND STORAGE TAIfiS (Comflete tu edr tank a[ $ls locdion.)
Tank tloJ TanR t{o.
-
Tar* tlo.
-
T. arf( No.
-
Tank }'lo.Tar{< ldenlificdim Nurter
l.Stdrs olTank(tnatodyone) Qtnentyhtbe
Terporadly Outof Use
F-raara..c-iLl
Pemanen0y Ortof Use
l--5tr-.a.rfl
Alnertdrngrt of lnbrnalion
2 Ddeol hstallatim (m./year)
3. Estimded Total C+adty Gaflors)S,fraal
4. lvlatedal o, Cortstuc{bn
(lt/brt all trd apply)
Asphalt Coat€d or Bare Steel
Cdrodcdly Protected $ed
Epoxy C.oated Steel
Composlb (Seel x,itr Fibeqlass)
Fibeglass Reinforced Plastb
Cotil -thn{lnledor
Dou6leWalled
Polye0rylerc TankJacket
Concrste
E<cardion ther
tldrnown
Otrer, Pleass spetily
Hastankbeen repaired?
Yl'x
v
5. Plprng (trtlderial)
(tt ak d trat app0y) BarB Stoel
Gahraniz€d Steel
Fiberylass Reinlorced Plaslic
Copp€t
Cdrodcdly Protecied
Do6leWalled
Seondary Contahment
'Udoorn
Other, Please spedfy
II
e.HphgGype)
(MataIfidapply)
Sr.rcdon: no vdve diank
Suclion: valve d tank
Pressum
GEvilyFe€d
Has piping been repaired?
4
EPA Forar 753G1 (Rcv. 2€2)PaEe 3
Tank ldenlifcatft:n Nurter Tarf(nb- /Ter*nb.TerI( ilo-Tard( nb.-Tar* l.lo._
7. Subetae arenty or Last Stored
h @eare$ Aranlity by Volunr
Gasofino
Diesal
Gcohol
Kgosene
. HedingOil
Used OI
Olher, Pleaseseedfy
Hazadous Sttbstarrce
CERCIJnarne ard,lor,
CAS number
M:<trreolSuHanes
Please spxily
X TANIG OUT OF t.,SE OR C}IANGE IN SERVEE
1. Cletir€ of Tank
A Estmdedddehstus€d
(rn./daylyear)
B. Eslimde date tank dosed
Frotdrflyernl
G. Tar* was rerrved fnom gund
D.Ta*wasdcedingumd
E. TarI( fifl€d wih hd mderial
Describe
F. Ctunge h 3evbe
2. Site Assessmern Corpleted
Evtlence ol a leak d€bcled
EPA Form 758G1 (R3Y. 2€'4 Fagp4
X. cERnFEATlOtl oF COIIPLIANCE (COMPI-ErE FOR Al NEW AND UPGMDED TAI'IKS ATTHIS LOCATION)
Tad( ldentficdion Nunter Tankib. /Tar* i,lo._Tar* No_Tank No.Tar* ttlo.
l.lnstdldon
A- lnstallercerlified bytank and
piptrE manutact rss
B. lnstaller cerlified or licensed by the
irnflementing aS€ncy
C. lnstallalim inspecled by a
re$stered erlginee
D. lnslalldim inspoct€d ard
appwed by tnplennnlirg agpncy
E. Manufactre/s irslalldirn
cfte*lists havs bean conpleted
F. tuidrer melhod allored by State
agsrcy. Please speify.
2. Release Ddedim (Mark all that apply)
A Manual tank gauging
8. Tar* tigfrtness testing
C. lrueitoryconfob
D. Arbmdictankgauging
E Vapormonitodrg
F. Groundvuder nonttoring
G. lnterslitial monito,ring double walled
tanl/pifing
H. tnterslitial mdnitoring/secondary
containnpnt
l. Aubrnalicline leakdatecbrs
J. Line t(ytfiess testirg
K. Otter rpfiod allrured by
lmplementng Agency. Please
spedfy.
TAT{K
EMwKErE
tl
E
E
PIPING
EEE
E
Etlt_l
TANK
EEEEE
t_lfl
E
E
E
t_l
EEE
PIPING
EEE
L]
E
tl
TAT.IK
EflEEEEE
t_lEEEtlEE
tl
fl
E
TAI.IK TANK
tlEflE
t_lEtl
E
fl
fl
PIPING
EEE
tl
EEE
I
EEE
EEE
rtrtNt|,
tlEE
E
EEE
rtrtN|.,
3. St ll and Overfi! Prdection
A. Ov€rfll devbe anstalled
B. Spil d€r,ice hstalled
,eto the bestof my beEel ard lmill€dgp.
EPA Fomr 7:53G1 (RGy. 2€,1)Fagp 5
!-G,aa-,-t-L-trr.arrr-
STATE USE OIILY
D }IUIIEER
D^IEBECENED TA Lq
A Do E r.rtd lnr oomg,lr
B. Dir E rry Cbtlr lntlrb
C. orn rWa0olmdP
Clrrly Rryrr" Comnuir
w
-
"n7o
lSirldt 5 trf- t f-U - E a.ngta tr5 firlrr -i r-fcroqrt.l.ItrrDlr-, t. tt a.fil _rth6rllr.tof 5f. rfrrrilr rrtr rrorrarfrlCt3. tlr hlrtlt rEr- r tr.- t t-Et r c l,r ar.!Cr-ilrlt.rt fcf fr+ ncfAl r rrrl
Tb nary frr C tr llliEt q'ttr. D E.r, ilrD
t rt U,l Era i3tDrDtttiD EtE Elrrtt, nrE. llEE
l a aDCa E n nErrrEr tls !rr- rl I EE c!.rrIr,tiJ-a tEEIr, n !I EE c, t Ii tE!. tu, W, *.9ISEL
WfD ltlr ,.dlft? S.ocr rc o, RCRI. ! rrdit. ,Eftt trl. ul-
aralrDta. ililr o, uDorlar! rra lttr nE! rtgt aE arrfE nu3
,Dtt o.fnrE Slr a a lrran c. na ar.I[E ct t!, rrlr orl!,
ltrl!-
rl h tr c.- c !l uurt'l, EI. rr n u- !r l5lnrrl. tll.g'
tsutr! nD rD dI t!o!.t, FrErrnc!'r -r u!.,! lrrE Et,trrr.r- En aEt.tltcErng ctEtlrt 3E E, t!
D h at o C rr, uurtilrr, E. rr n tr tlt lffrtr l.
taa. t trDlrrp?a t- lt n3c.'tr r.tEtrlDcEla at ! !thrrrDt bEt Et 6EUrrEt C lr tr.
c,Itlr $a Sq acrErr !? E'Gltr uttF Gl G'Ji!
D lElt ltlrEa c lu ryrrn og 1crt rilrr rr irtnut rcD!.ndl!.l,}
tlrt tnE lrt fg-a, Uri.tlul! tE. rrf I rtfr t
',/r1
ts
ccEtE rErc,EIr nr0) buE D.rrrtr E rrEtdrurdrE-C.'l,I, Cl, rE E L(rElarDEtEl IrUUur! Etf Itcf o? nEi frralr fr gulf. Serr alrrrI alt uDttlrErrr ar[ aEtIE
L o|.drr. u5 c., o- rra. rl e iEa|I gf,E. Fto.e.lllcct noaal.
*il t at tlrt Erilfl?ftt rffi lul nrgruttarudl-r tuEn Olr lrlr.rltlr tgrt llllatlt -t:
t. tsllr r i.rlla Dfr c, t JO CfEr r r. cEst, t- E.Ellgargtl tstsurrrrul r,r:
a rrE lI- tsrtEur rrlE cl b qurrr rro Cr tr t tltrlrnrttatd;
L OWHERSHTPOFTAilK(S)
IEI'IA
a lrd! Sfr alElt! SErr! tlrl ttr lt tli?tr llrnl O-
ntr Stsf faa tC. rsr-tUan f.nro Pllr gry EC tgn. q
rnEt I fr rlrr roar Err trn uir 8D ra
arr1E|tErurn l|.Eu.rEr:aErrlEttrrtElEttltrll:7.!*rruprrrrrrr:ahll rucr-- glra f: CuT tE D C c, F
tEErn!FrntcE- rrguirrl-c aenurrrrurai. 1.!n-.r.r:!r.o'tnnElni. otlt .rn, tltra) l, nt E? ril! rlD rEl c a! t'
tll5Ctrts
illl lr|EtI fn Gd? Tlr lilllaa rarrrrrr
'Eul
o t'f'
it!r5 eru rrrt tIttD(Ea 'ttrrrll rrE,pr rhr tEE "naEE oirO r AEfEa n rgl tol (tal ol !r csrurr.l'
Errr ilnrr.Gmtrr El.llIrh,A.tCtIOGErclI)'rlUl
nD Et C nn fEU rlrr/E I rrtEl In Ur E !61 C ol
rcer. r ir r.rlr rrnnr. rj- ern c t a i-ttrrrrlilgl t
lcr I grr csirr c rruiron "EE'E, lto sL' F.nuril
rr, la.rEilrrrrr.Ettr.rla}
IIln lc l.ef'? S.! Etllld Elll E
UDEO'DERF
t8t NoFIH t950WEST. tllFt.ctOB
SALT I.AKE CTTY, Uru{ 8'II8
tt aa ntf, t. t.Irrt t uElrrt-Ir rE a lt t ttll l!r'
bo llm qr c oirur rr.:rrv i. ti?a.E dl alra.ltE mlrrlty
!l rtl tE t'iiltiDDat! Itirvlr! Et {rEorr"t' ll,
f . rcal-;rl tfttrrrlo cn d lrrlf r rrr nEret tltr sD
riur r*dd r" ttrEll[ r grf r'! rtlutD SD Tqtrlldrrt.
htfts l,tt rri. Erff,, tI b till, rrtli! b lrtst'D
tEr.l{ r i{- a..m rili rrr rood ttE DEtsrrtrr E
rtfr rs ni f r glri r rrr$ar tr. hffih b rild.
rLLOC TpilOFTAIIK(SI
TY?EOF}IC'TIFICATTXI
fl r ilElv FAcr.rry E a ^MEHDED trl c49Pl,HE
E jif,-a-uil.?Erl,--:-0-,-ib."ffi ffi-.E;A;.d
NSTBT'gTrc'illi
Pbll. ULgLffflJS.E! rll trtl rraB tgnatm' h tdl V. Thb tofltt
murr r @ coarirtn llrrrgrut tto ry trnkl l,
nEtt dllr lhr. (O tnia rr ffi n frb ElDn Wl thr lo|brtlr
rh..lr. lnd rtrpb E nhunirn tln E th. lom.
|^et erlr,LOr
461 West 4380 South, Bu'il di ng "C"o-rrt-lrr.lrr-n I I
Salt Lake City, Utah 84L23_E
Sal t Lake
( 801 ) .268- ?02etD-tEf.=-.-i:
fcrllrr-EtaDI-.rE
Hosoi
,l?!.EEElDdrrison Boulevard
0gden, Utah
Tsnks arc locatcd on lild wilhin an lndian
nciirvaion oron olhcrtrust hndc'
Tanks are owned bY nallvc Amcil:an
natn, tribe, or indivHual'
, IIt. TYPEOFOWNER
Et FeaeratGovcmment E Commercial
E srare Govemment E P;vae
E lrcalGovemment
Selecl $e ApProPrhte Facitity Oescription
-Gas
Stdion
-
Petrolcum Oistribulor
-Air
Taxi(Ahline)
-Aircrafi
Orner
-Auto
DcalershiP
Railroad
-LocalGovcmmcnl
-state
@vemmcnl
-
Fcderal' Non'MilitarY
-
Fcderal'Military
-Commcrcial
-
lnduSdal
-
Contractor
-Tru*ing/Transport
-
tltilities
-Farm
-Rcsidenlial-LOher (Explain) HosPi tal
VI. @NTACT PERSON IN CHABGE OFTANKS
Nsms Douq Garmeyer Tilb Enoineerinq Deoartment. Manaoer
cfyOqden
$are.uEb- zip 84409Address 3939 Harrison Boulevard
phone [phone]
FgnnnCenON (Read and sign aflercomplcting allsoc'lions)
I certify under penally ol law thal I have personally cramined and am lamiliar wilh the inlomalion submitled in this and all afiached
doqrmenrs, 8nd rhar based on my irquiry or rnoiS iiiiiijliii.-iiirJaiely rcsponsible lor obtaining the information, I believe lhd lhe
IririitJJiitormation is lrue, accurale, and omplete'
Dale Signed
/ 7 ,c'Pu, qq
Name and olliciallitle ol owner
oi ownert authorized tePresentative (Pdnt)
*"r" Dwight Solomon
ad1" D'ir. of Engineering Sei vices
Vlll. FINANCIiAL FESPONSIBIUTY
I have met lhe linarrcial responsibility rcq-uire.menls in
-
- - -lc"iraan""*ith40cFBEfid;i{'
.-ibrcteone')
UEy NO
Check Allthat APPIY
t...Fl Sc[ tnsurance
"liiidiil&it is notilication lorm may be used while supplies last'
EpA estimares public reporting burden lor this form to average 90 minut$ per ?e3Pomc indudiry time lor reviewing inctructbns'
rffii#"#;d?ffiffii*"',;mai:t:s"r*:Hls':lgt"dul',il".fi[rl&::?Iir4iffilif,.3:.iif-,;l;435:".Anenrion Desk ogicer ior EpA.. This ,orm ameiJllrri-iiir,riorr nailication lorm as Print3d in 40 CFB Parl280' ApPendix l. Prevbus
rY nEecQlPTl(,)N oF - TERGROUND STO nlef nnXS (ComPlctc 'rn tank atthis location')
Tank No.-,L Tank No.-Tank No.-
ldentilir:ation N umbe r Tank No. 1 TankNo.-l
A. Status ol Tank
CunentlY in Use
Temporarily Out ol Use
tri.irSaor*tl,
Permanenlly Out of Use
tki-tt !alol.-aqrrl
1986 1994Dale ol lnstallalion (mo.fear)
1 q58
500 500
YES /NO
Estimaled Total Capachy (gallons)25.000
plv)
x
YEs lNA
x
6
x
YES / NO
B. Malerialot Consfuaion (Mark allthat al
AsPhall Coated or Bare Steel
I
CathodicallY Poiected Sleel I
EPot<Y Coared Steell
Composite (Sleel wilh Fiberglass)
|
Fiberglass Reinlorced Plasiic
1
Llncd lnterior I
Double walbd
I
PolYelhYlene Tank Jacket
I
Concrete I
Excavarion Liner I
unxnown
I
Oher, Please sPecilY
I
Has tank been repaired? (circle one)
C. Piping (Matetial)
lMar{ aitrirar aPPtY; Bare Steel
Galvanized Steel
Fiberglass Reinlorced Plastic
CoPPer
Cathodically Ptotected
Double Walled
Excavalion Liner
Unknown
Oher, Please specily
r
D6ubIe Wal
Envi rofl ex
YES / NO
O fiping Fype) (Mark allthat apply)
Suction: no check valve at lank
Suction: check valve at lank
Prgssure
Gravity Feed
Has piping been repaired? (circle one)
f
YES / NO
Fage 3
Tank tdentilixtion Number \Tank No. 1 TenkNo. 2 Tant^ -.,]-Tank No.Tank No.-
E. Substance Cunently or Last Stored
ln Grcatest OuantitY bY Volume
Gagoline
Diesel
Gaeohol
Kercsene
Hcating Oil
Used Oil
other Petroleum Produc't
(Please sPectty)
l{ nol a pelroleum Ptoducl:
Hazardous Substance (circle one)
CEHCLA name and/or'
CAS number
ll not listed above:
Mixture of Substarres (circle one)
Please sPecifY
IYES/NO I
---i I
I
IYES/NO I
I
I
I
I
l
I
I
YES / NO
YES / NO
YES / NO
YES / NO
YES/NO
YES / NO
Y'ES /NO
YES/NO
X. TAruXS OUT OF USE, OR CHANGE IN SEBVICE
Closing ol Tank
Tank was removed lrom gound
Tank was closed in ground
Estimated date last used
lyyyar)--
Eslimate date tank closed
(mo.ldaYtYearl
9/93
3/28/94
Tank lilled with inert maierial
(indicate material)
Change in seruice
Sile Assassment ComPleted
(circle one)
YES / NO @*"YES / NO YES / NO YES/NO I
I
Evirjence ol a leak detected
(circle one)
YES / NO @*"YES / NO YES / NO YES / NO
Page 4
PaDED TANKs ATTHls LocATloN)(coMPLETE FoB{l_-
,
Tank ldentilicalion Number I Tanf No'-
,.. lnstallation (Mark all that epPly)
lnstaller certilicd by lank and piping
manulaslurers
lnstaller ertilicd or licensed by lhe
State
lnstallation insPected bY a
rcaisered engi6eer
lnstallation inspecled by local or stal€
t9ency
Manu{adurer's inslallation checklists
have been comPlelod
Another method allowed bY Stale
a9ency.
Please sPecitY.
PIPTNG
EEE
il
EEE
TANK
EEEEEEE
E
PIPING
EEE
tI
EEE
TANK
EEEEEEE
E
PIPING
EDE
E
EEtl
TANK
ilEilETtlE
T
B. Belease Detection (Mark allthat aPply)
Manualtank gauging
Tank tighlness testing
lnventory conirols
Auomatic tank gauging
VaPor monitoring
Groundwater monhoring
lnterctitial monitoring double
walled lanUPiPing
tnterstitial monhoringlercavat io n
liner
Auomalic line leak deleclors
Line tBhtness testing
Other method allowed bY
lmPlementing AgencY.
Please sPecilY.
TANK
TT]EITiII
I
EilT
il
ilTT
\ES / NO
YES / NO
C. Spilland Overlill Protection
I
Overlilldevice installed (Circle one) | YES / NO
Spilldevice installed (Circle one) | YES / NO
ilIE
E
l
t_lE
YES / NO
YES / NO
YES /NO
YES / NO
4/L8/94
,
Tetra Tech, In!.
Date
TY"E OF}lc,TFICATT'il
B. Ddr Enry Cbft tnilrb
C. OunorWrrConUdt
_Eryg*FAcury _tr__ iro. a tr*r a tlcny - - - ib.? ;ffi,fi;fifr Afird-
_ Pt- twi.l q? ?rlil ln _hk.dt homr .ro.F :tignatun, h t Gilon V. Tht, bmtr,r!t F qFpr.rcd ror cadr bcainn gqaihrrg-unocrpmunc-gdec-drt" nprl}TlTl_tt?lf: rn own d a urr lcJin, pri,ocoey-rri7o-tfriotnflq rm dtpb ontinurtbn rhcotr to $.lorm.
-- }en iOE-r.EL rrf,t-. iaE fCrE ., qlr E,!r,
(l..rt.t-lrrtmtUfr ! t
Fdy lfrrr c Ocr9r1 !b tfr.. eE
Mcl(av-Dee Hospital
il
e5.D.rlE-FrErahDrE ttt
STAIE USE O}ILYNo0llcallon for Underground Slorage Tankt
-_!$!ib.r.f ncr* t tru Ir E r .rlrt,ura lfr. Ur
=1:In:I lo-ro::.IttFlrd .ur.rE d,ro .rirrry r. rrrr. urff#ffitr:'J!'dE?Hts"#r*lsGqrrrrm er noriry ra. ririifl r iifrI' -
.Tb p:try grpr C rr luior Flgrrr l. E Doro tr! allrtJrtlrurE rra =c tEtr, !!lr turc-ffrun c.rrarul eaolEtt L orp.od lla h. tntlrrubn ,orriroru5 * r iiii-orr nrqd,.vrLU. ,tE!., a h ,ro eblni ot'.,rO, ,r-rt , V., frirf.Cg..Eif, orrdodru
Utr lct ltcry? Socooa g!!A
9t RCRA. r. ln id.d. nql-t! tra uir.itfi*&f*^.il#f5sffi eHT,H*i:m
lfr* - ot n ndrrgurn orao rrr rn uo or i.a,rrslrr. rtr . alqfm !p q. Or rr Ori, rf rrri rrp anr n rnir!,!u! onelrrl u..d b [r mr1r. uro. c rirbrnril a rreinJ liurp., rt
-^^9.h lI !.- ol r? ln(l.Q,urt rB!. ff h lr bbo |trntrr a,l$a. lut,ptor,te.rir rr qr dl&r. rryir..rinoaaid rtJdr lrrrnnrtl.rtt b.bo rh. du1ur,.ur'ol tirir.
"'3iffifiiffffiffih"Hy#HffiffiD b. hdud.d).
WIrt ?rrf. &. lrEttxbl?urd.rtlD(nd rEreo d b Otrrd I !l' qra ontindqr o, !r*. h.t (r) r. urd-l srrrn lr-reilU, a.n Sfii=r.otlu .'.nd O.ru. il.r,.-r,rsJ,re-.i.ilItrf,,rrr pgr, bFs!r,IHJ?#A*;mm:ffi riFffi 'luticidot a irail.n!"
" "Hlm#ffi]ffffim.,:i epu,,'d n,u r{G
l. hrn a rdrlratd dr-o, l.rCO e&nr o. L.t Trdt, l.Id b rUta,tDE lr! b rEiqnnruf ArE-;
*1!l!_!d b rEhg h.rtl on
-Or rrnrytr lr. !r h rilta.rulr&rl(':
t t gacr*r;r#i!ffffffiftswBS.-Ef ! TEqr rorr tiilr r*uc,ry slr- rrr. lriE Filn,r[i!![r r!r, FII., rtsGr:
a. rErn ru r ralr rE 6-r.GDlr ryiltr:7.t*lruahgordt;
|. Iqfd rT. a r.dd-edtrtrt h.. it r, nlt.t E d q el.Furrtr!rnrtlErlricfUr:t aEfoa !fI! aGC G ]r.{Ea.D!our! a,ta trrn aa a lt.llrrf. Oalf.nrtlerqtllt3. qdrt, dul! r rarrt) lt lroiurer-lrt ]r rii rrqr,.born,r.n toolh.bd.
S'htubtrrrr fn Ccvrrd?Iho nodficdon nCdililrrtr.pC, b ui.?g[o|Jnd dr{. arao fi.tconEin r{rrr- e$rnror. i}ijt clr6..-rr- -.--
lgga :!qr D rrzrrlr h i<m r oi-trrt or da'a;F.h.,rJvi
E ttrrDflit tE eregor. Conp.Irlo uO Uury fa A tdO tCenq.rf t, rilrt! oneEa d frr r..E.r,te,rDd -hoa;C;-;. $n . &bdd. Crcn^-f !?_ hctfi_prdrun, od.. orf -, t'-8, altot Jich bXllO C r.il! EfEr d r,rpa.G.|t arE ElrF CO Og|to frnrrrrrt ta.7 DOUrtt ta. tpar nEl rlorral
Xllrr ?c tlCffi Sond onptod bm b:
U?AH DEPART!4ENT OF HEALTH
BUREAU OF E}WIRONMENTAL RESPONSE & REMED.
288 N. r460 ,{., P.o. BOX 15590
SAI,T LAKE CITY, UTAH 841 I6.0690
- Sba?c llnfya t. CLlrt oa uro,lrorl{raDrta Ilu n llo or lrl nrib.n r*rl orl ot rucr drr..Lr,.r, i, rglr.U-iu-rrinforirc. ;* ;"ryfF-'rifi ,i*..rHrffi l"#H#,li,gil;
"rqme no*an c or r,r-"ru ; t&ry t r!-;d', I siiiErqtntnfott.
lrrlb:.lny tr in fnrtfy f I b rr.tf, c rtiar bb hhrrr.hr til b rqd r r *r pnfr ,nr. iii&G6r r ra, r,u Lrildr rulh.i r'a j.-,? -'*i-ffiii5o b ,.nira
* CHANGE
COIITACT
OF ADDRESS
PERSON
OF OLI}IERSHIP AND FACILITY /I12OOO9O Prf I
\
IlT TY?EOFOUVNER M.INDI. ,:
tr F.d-rtGornmmonl E Conrmodrt
tr $rtr@wmmorl E Pturo
tr Lal Govcmmon0
Tankr rro locd.d oa hnd wthh m lndrn
Rc..rdbn o, on dh.? trrl bnd..
Tedc rr ou,n d by ,rdhr. Am.rbrn
ndbn. ttc, orlndrfiud.
TtDoorN&a:tr
tr
v.Tl?EoFF CIJW
S.ld $. feproplHc Fdly Ocailfn
-er!t
Sldbo
-AlTrrlfiHn
)
_Alrcrdfin t
_AubD.rLr$h
_TrudthO/Tntrpot
_R.old.ntlrl
-Fsm_Othcr (Erplrln)
_ PftoLum DHdh4or _ F.d.rd - i5n-Miltuy
-
t dU.r-Befod
_F.dcnl- MUtly
-hdutfrltl_Contrbr
VI. @iITACTPERSON IN CI{^FGEOFTANKS
Nemc
Dwight
Solomon
JobTfb
Director,
Clinical Engineering
Addrec
461 West 4380 South, B1dg.
Murray, UT 84123
Plpnr iluntor (lndudc Aroa Codc)
C
[phone]
VI!. FINANCIAL RESPOi{SIBLTV
I hwr mct0rolinardel rcsponsiblllty rcqultlmcntr lnredrno wl$ tlO CFR Subpst H
Yllt CERlTlFlC Tpt{ (R..d nd dgn dt , cotttPLthe d ll.lbo.)
I crrtr, undcr ponelty d hw $f I hm porlonrlly oHmhrd lrd rm hmllu uilh th. hfoflillbn rDmll d h fib .nd d dedtd
dqp1 "i.rilt eriC trr'UuO on my hqdi ol tro.a hdiyUurb inmcdirt.ly ruponOb ta oU-ring th. ittbmriln. I b.lbw tld 0lc
rtto!.d Hanndon b trto.slrb. md ocplrlr.
lLrt ltdollk rltlodctu
or ornefr a,thortsrd :WtIrmOr (P]tl)
Dwight SolomonDirector, Clinical Engineering
Shac(t Ddr Slgnod
2-25-91
/
EPA rcdmacr prtlbfp nportirg hrdon brlhb lorn E rvorego.30 qhYt.s Pr-t tpog. irdrding lmo |ot rviruhg- iuhrclim'
od*lp rrt rtrintttrio-tro-oar noraoo rnd omplrrire ind rrv.wing tiro forn. Sond commllrtl neudt! t!-_tu(on .!ritrd. b
fr-U, inFo-ailPott-Bnndr W-ZB,U.S. Envirbnmcirrl Protodon-Agomy, 4Ot U $rlc t WohhgtonO.C.-2OaEO, mrdcd
.fnriiUm Oesr. Oricriig-if'nrr to,# rmcndc tlr prvlour nofiicstba bdr u prht d h tto CFH Put 280, APgortdL l. Pnvbur
rdnionc d thb notilhrrion brm mry b. urrd wttllc rrypllcr hn.
PrF 2
'Ifln' |",#ffiHUrl 'o
P.O.Box45500
Saltt-akeClty, UT
STAIE USEOT{LY
l.D. Numbcr / .. 4. \i - r I -. '-, il
Notlttodon b rcqdrcd by Fcdcnl hr for rlt undcqrorurd frnt! drrt trrrc Uil
u.d ro taolc r.tutrtld srbcLnccr rincc Jrnurry t. t97i. thet rrc ln thc Arcund u of
Mry t. 19t6, or thrl rrr brouthl anlo usc eflc Mey t, 19t5. Thc lnformedon rcqrnilcd .
b rcgdrcd by Scctlon 9002 otthc Rcsourcc Conrcrvrtion end Reovcry Ad,(nCRA),gltncrrilld.
Thc prirnary purposc of this notification program is to locatc and cvaluatc undcr-
ground tenks that storc or havc storcd pctrolcum or harardous subsuncrr. lt is
crpecrcd that thc information you providc will bc bascd on rrasonably availablc
rccords. or. in thc ab,scrct of srrh rccords. your knowledgc. bclicf. or rccolhction.
Who Murt Notlfy? Sccrion 9002 of RCRA. as amcnded. rcquires that. unless
axcmptd. own€rs of undcrgrourd tanks that storc rcgulatcd substanccs must notify
dcsignetcd Statc or local agcncies of the cxistcnct of thcir tanks. O*ncr mcans-
(e) in thc casc of an undcrground storagc tank in usc on Norrcmbcr E. 1984. or
brouSht into usc aftcr that date. any pcrson who owns an undcrground sloragc tank
uscd for thc sronge. usc. or dispcnsing of rcgulated suktanccs. and
(.r) in thc casc bf any undcrground storagc tank in usc bcforc Novcmbcr t. 19t4.
but no loogcr in usc on that datc. any pcrson who owncd such unk immcdiatcly bcforc
thc dirontinuarion of irs usc.
lVhrf tnb Arc hludcd? Underground storagc unk is dcfincd as any onc or
cciabi::elic:: of anks that ( ! ) is uscC tc coataiii aa accumulaticn cf 'rcaulated sub
sunces.- end (2) whosc volumc (including connectcd underground piping) is 109[ or
more bcncath thc grould. Somc cramplcsare undcrground tanks storing: l.gasolirr.
urcd oil or dicscl fucl. end 2. irdustrial solvcnts. pcsticidcs. hcrbicidcs or fumigans.
Wh.r lrnL Arr Ercludcd? Tanks rrmovcd from thc ground arc not subjca to
no{ificetion. Oihcr unks cxcludcd from notifrcation arc:
l.frrm or rcridenrial r.nl6of l.l00gallomor hsscapacity uscd forstoring motorfirl
for nomomnrcrcirl purposcs:
t. untr used for storing hcating oil forconsumptire usc on thc prcmiscs whcrc storcd:
3. scprh unkr:
bfpctifn{fMtit* (including gathcrinS lincs) rcgulated under thc Natural Cas
all${STcty Act of 196t. or the Hazardous Liquid Pipclinc Safety Act of 1979. or
lilE is an intnsutc pipclinc facility rcguhtcd urdcr Statc h*s:
surfact impoundmcnts. pits. ponds. or hgoonsl
6. storm *atir or uastc waicr colhoion spicms:
7. flow.through proccss tanksl
t. liquid tnps orassociatcd gathering lincsdireoly rclatcd tooil orgas produoion and
Sathcrins opcrations:
9. storage unks situatcd in an undcrground arce (such as a ba:rment. ccllar.
mincworking. drift. shaft. or tunnel) if thc storage unl is sitrnrcd upon or abotc the
surfact of thc 0oor.
Whrt Subrrrnca Arc Covcrtd? Thc notilication rcquircmcnts apply to undcr-
3round sorage tenks that conuin rcgulatcd subsunces. This include; any substancc
dclirrd as hazardous in scction l0l (14) of thc Comprchcnsivc Environmcnul
Rcsponsc, Compcnsarion and Liability Acr of l9t0(CERCLA). with the cxception of
thosc subsuncca regulated as hazardous wastc urdcr Subtitlc C of RCRA. lt also
includes pctrolcum. e.9.. crude oil or any fraction thcrcof which is liquid at standard
conditions of tcmpcrature ard prcssurc (60 dcgrces Fahrcnhcit and 14.7 pounds pcr
sluare inch absolute).
ith.rc fb Nodfy? Comphtcd notiiicaiion forms should bc 'rnt to ihc addres
giren at thc top ofthis page.
lYhcn To Nodfy? t. Owners of undcrground storagc tanks in urr or that harc bcen
trkcn oul of opcration aftcr January l. 197,1. but srill in thc ground. must notif! br-
May t. 19t6. l. Orncrs *ho bring undcrground storage tanks into urc aftcr Ma1'E.
19t6. must notify within 30 dap of bringing thc unks into usc.
P5n ltie An, orncr rho lnowlntly frlb to nottry or t|Dmlls frh. infonnrrbnrblt bc lblcct to r clvll pcnrhy not lo crced t10.000 for crch tu* for rhlcf
mtillcetirn ir not dwn cfor rhklr hkc ldomdoo b ruhnincd.
Pleasc typc or print in ink all items exccpt'signature'in Scaion V. Thbform mut by complcttd for
cedr locedon colrtrinl4 underyround slongc trnks. lf morc than 5 tanks arc owned at this location.
photocopy thc rcr,ersc side. and suple continuation sheers to this form.
lndicate numbcr of
continuation sheets
anachd
(ll same as Section 1, mart box herc Ll )
Facility Name or Company Sito ldentilier, as applicable
ZlPCode
Mark box here il tank(s)
er€ located on land within
an lndisn r€son,alion or
on othor lndian trust lands
Ownar Name (Corporatiofl, lndividual. Publlc Agonqr, or Other Enljty)( l2}g
tu {\-1l.-|.-\ot} N \A\ )!, \-\\a:At fA (A4J--.- \ N('
StrcatAddress'3ci-, 1c., (;\xTr= :=T z--z-14? tr=uoota
Cgfnty t\-\L--C t r.k*f=
city . siare ZlPcpd/eS=*..- L"s'vrrs L\rxrr (4 tr t
Ar!! Codc Phone Number8ot E3=.-Z-z8z-
Type or?rrner (ilcrt Jl ilra rpill8 )
I StateorLocalGot't
t{arne (tt lame es Soction l, mark box here f] }
'l 6.zq-zo-LZ
tr Mart box here only il thls is an arnended or sub$quont notilbation lor this location.
I certify und€r penalty of law that I harc personally examined and am familiar with th€ information submitted in this and all attached
documents, gnd flat bssed on my inquiry of thoso individuals immediately responsible for obtaining the information, I b€lier€ that tl€
subrnitt€d inlormation is true, accurate, and completo.
t{flm afid ofiIcial ttle ol owner or owne/s authorizod l€prElantetiyo
Thonras d. Hanrahan, Associate Administrato
ownerl{rmr(rroms.cumll { 4 C- \,ZE Locr[on (trom s*u* rrf &s.&r,=D=rE-6Ya4r ro. ' I o,J*aepr
Trnt ldcnUflcatlon No. (c.9., ABG.lZl), or
Arbltnrlly Atrlgncd Seiuintlal Numbcr (e.9., 1'2'3.-)
Tank No.
I
TankNo.TankNo.Tank No.TankNo.
l.StelurolTenk
(ttttl*cn ttnt,rldyat r.-*3'nfi3l1l||U;
PermanentlyOutof Use
Brought into Use after 5A186
r-Kt
l-]
l-]
l-1I-]
2. ErUmrled Aoe (Yean)
3. Ertlmrted Tota! Capoclty (Grllonr)
l. Melcdrl ol Condructlon(Mcilu,,a, *'
*^]fj
Fiberglass Reinforced Plastlc
Unknown
Other, Please Specify
lYt
l-1
l-l
- l-1
5.lntemal Prolecflon
(Mat* ett ulrltopptyg) cathcdic Prctectlon' - Triterior Lining (e.9., epoxy resins)
None
Unknonn
Other. Please Specily
rYl r-'l
0. Erlernd Protec{on Cathodic protection(if'ddltlntew'ya) Fai;ted6.9.,asprrartic)
Fiberglass Reinforced Plastic Coated
None
Unknoum
Other, PleaseSpecify
l-l
l-'l
l-1
r-1
l-]l-r
7. Plplng Bare Steel(Maildllltl,,lawry8,J GatvanizedSteet
Fiberglass Reinforced Plastic
Cathod ical ly Protected
Unknorn
Other, PleaseSpecify --6pe:lz
&SuQrtrncc-Qgrcn0y.or.tststoted .. EmptylnGrcetcrtOuantltybyVolum b. pebohuc!,(Ma*illlnttmtYu) Di"ue!
Kerosene
Gasoline (includiqg alcohol blends)
UsedOil
Other, PleaseSpecify
c HlzetdotrrSuDatmca
Ptease tndicate Nameof Pdncipal CERCI-A Substance
OR
Chemicat Abstract Service (CAS) No.
Mark box tr if tank stores a mixture of substances
d. Unknown
rFl
1,1
t-]
E:=
l-1
E=
r-1
r-1
t-l
r-I
t-'l
3. Addltlonrl lnlonnellm (lor tankr pcmanently
trlon outol rcrvlcr)
e. Estimated dete last used (mo/yr)
b. Eltimttod quantity of substance remaining (9a1.)
a Mark box I if tank was lilled with inert rnaterial
(e.9., sand, concrete)
I I I I I
t-]I-1
EPA Form 753O-t (tt-85) Ranne It*cornilt FLthio't br laaa{ta'rto Ptr-2
a\
i lt-;i,{ :ttBjtit=S,iil;=ETFlt lo)tll,t--. ll,t tltr /. I
Addi ti ona'l I nformati on
(State use 0n'ly)
STATE USE ONLV
Sheet
l.D. Numbcr
Orlc Bccerva6
This fonri'is t,o be used only to gatherinformatioon by telephone.from tenk owners/operators
ihat r'Jas oo-u grovi cied on ',he not'if i cati on f orm ori gi na11y sub;n'i tted.
Date:
hdEC
3'to'X7
of Ferson Cont,acted:
S'ig.nature of Ca'l'ler:
P;c2s. l\F oi'3inl r:: ini: aii itens cxerl -sig:-,ature- ir, Sc.crion \'. Thb form mus by cornpicred for
erci icrcanon conreinrng undergrounc stor8ge tenks. lf rnort than -( t3nksare ou'nec al thrs lcstron.
iiJic!:'.-,r.\ rh: -r':sc srCe .3na si'zpie conlinuaijon shets to tnis form.
r ngrc:le nu:ioer ot Icontrnuarionshers i I Ia:"acl:: I
Crw.f r Na:re (CC-?:rzt,C..,nC,vrcu8l. 9uD[C Agenc,v. O. Cthe/ :nttty)
Si'ee: ACCress
Gcunty
ZtP C.aoe
Area Cooe ?icnc l.iu'-nbet
Feoerai Gorzt
(GSA lacility l.D. no.
Nanre (lf sarDe as S,eciron l, mark box frrr. E f Job Titlc
D
tr
orv
TyPe
tr
tr
of Onner
O;rre-rt
Forrner
(lAa* ell tl.t.pptlE)
I S,.r, or Locat Gor't Private or
Corporate
Ownersnrp
uncerEln
Area Cooe P'rone Number
t E Mart bor here only if this is an amerded or suDs€qucnt nciitication lor thts locetion.
I ce:"iify unoer p€naliy cf law that I have PeFonally examined and am lamiliar \ilti :he infor:.,ation submined in this anc aii attacheC,ocuments. anc tl,at based on my inquiry.ot those individuals immediately respons;Dte ,or obtaining the inrorrnation, I be rigrqp tnat th;iubmined inlormation is true. accuate. and complete.
1l{ same as Seclon 1, marx ao, ""r. fl I
Facility Na-re : r Sornganv Sile loentilrer, as appticaote
Street Aocress or State Roa6. as applicabie
tioicate
number ot
lanks at fiis
location
t{arX Uo, here il tank(si
are locetec on land wr:rin
an lnoian rGervation or
on other lndian trust lsncs
l-t
E Substanct Cunently or l-ast Stored
in Greatesl Or.rantitY bY Volume
(fta* altWt apptv8.)
- Gasoline (rncluding aicoholblends)
Used Oil
Otner, Please Specity
c- Hazardous Substance
Ple:se lndicate Name of Principal CERCL-A Substance
OH
Chemical Abstract Service (CAS) No.
Marx 5cx E t;:anx sicres a mix:;:'e of substances
d. Unknown
rt*r Nrrvrr (trom S+ction ti LocrUon (lrom Soctlon ll) I Pegc Nc
-of-Prgcr
bnx loe'rtifrcat,cr )lo. (e.9.. ABC-13).or
\rt*trarily Asegrx{ Seqrpntral Number (e,9., 123-)
I-l I-l
Tank No.rankNo.
I
2 Estimatec Aoe lYears
3. Estinrated Total Caoa Gellons
4. Materiai ol Conslruction
(Mam oneg)
l. Status ol Tanx
(hiark ell trEt aDPlytr))
6. Erta.nal Proiection
(ll,an alinai epptyZ)
7. PirrnE
(Mar al;irial apclvZ)
. Cunently in Use
Temporarily Out ol Use
Permanently Out of Use
Brou_oht into Use atter 5/8/86
Sleel
Concrete
Fiberglass Reinlorced Plastic
Unknown
Cther, Please Specity
None
Unknown
Ot..er Plcase Soecrt-r
Sare Steel
Salvar,lzec Sieel
i ;:e;'c las:, i eirri crcei -r'raSi Ia
Cat;-, >c rca I ly Protectec
Unknown
i-rI-r
ri
5. lnlemal Protestion
(Mar* altthat epptyg) cathodic?rotection
rjlerrcr Lrninc (e _c., epoxy resinS)
Ce:rociic Proteclion
irainte.: (e.9.. asphallic)
r r ::'g iass.iei n1c r-cec P lasiic
"^fj=
Unkncwn
O:ier, Dieas€ Srecifv
Otner, Piease Specify
9. Additional lnlormation (for tanks permanently
. -taken oul ol service) !
a. Estimated date last used (mo/yr)
h Ee.i-2iod e,i2 ^l;:v C{ SUbstanCe re.-nainin,O (9a1.)
c-. rr,,arx oor E il iank was ,,,,.e":Jl."XiTr;Sr"t.#i
i.l
i-l
r-1
Distribution: White-DERR, Yellow-lnspccto.
The UST system is filled by transfers of 25 gallons or less. lf yes, spill
and overfill prevention is not required.
ls there a spill contrainment bucket or another device that will prevent
release of product into the snvironment?
ls there an overfill prevention device installed on the tank? ll yes,
indicate the type of device: Ball float (in vent line), Automatic shutoff
(in ltll pipe), Alarm, or other (specify)
For overllll alarm only: ls the alarm located where it can be easily
seen and heard by the delivery driver?
For overlill alarm only: ls the alarm clearly marked to indicate what is
meant when the alarm sounds?
lndicate the type of corrosion protection: Noncorrodible material (FRP),
Composite steel (CS), lntemal lining (lL), lmpressed Current (tC),
Sacrificial Anode (SA), or Not protected (NP). l, FRP or CS do not
complete ths remalndor ol thls sectlon.
lf the UST is not protected, was the tanMine installed belore May 7,
1985? It yes, corroelon proasdlon ls not regulred untll llec. 22,
1998; do not complcte the remalnder of thle eectlon.
The results of the last two cathodic protection tests are available.
(within 6 months ol installation and every 3 years thereafter).
Results ol the most recent cathodic protoction test.
For lmpressed curent syrtom: The results of the last three
equipment operation checks are available. (Equip. check required every
60 days.)
lf the tank has been glpft (lined or cathodicallv orotected), indicate
the date the retrofit was comple=ted. q - q, .a
understandthatthefollowingmarkeditemsmustbecompletedby
December 22, 1998 in ordor to meet the 1998 upgrade requirements: E Spill prevention for tank(s)#
fl Overfill prevention lor tank(s)#! Corrosion protection for tank(s) #
fl Corrosion protection for piping assoc. with tank(s) #,. fl Tllty meets 1998 upgrade requirements.
Distribution: Whiie,DERR,, Pink-Facility/Owner
,\\ UST lnstallatiory'Upgrade Notification-
The Utah Underground Storage Tank (UST) rules (Utafr Aaministrative Code R311-203-3) require that UST installers notify
the Executive Secretary, Utah Solid and Hazardous Waste Control Board, 3O days before installlng or upgrading any regulated
UST system. This form has been prepared to assist you in providing this information. Before installing or upgrading an USTsystem, please complete this form and return it to the Division of Environmental Response and Remediation at the addressbelow. lf an tanks or lines are removed or replaced, a Closure Ptan for those tanks or lines must be submitted and approved,
and a site assessment must be performed at closure.
Facility lD# (if not a new facility) 12OOO9O [ ] New installation I X ] Upgrade
Date work will commence 9t9t96
Tank Ourner lntermountain Health Care Phone # [phone]
Address 36 South State, Suite 23O0 City Salt Lake City State Utah 84111
Contact Person in charge of tanks Roger Mackey
zip
Facilfi Name McKay Dee Hospital
Address 3939 Harrison Boulevard City Ogden State utah zip 84409
Contact pe6on Scott Anderson Phone # [phone]
Certified Tank lnstaller Name Don Leach
Company WasatchEnvironmental, lnc.
Cen, # TLOOl6 Exp. date 5197
Phone # [phone]
Address 22zlo West California Avenue City Salt Lake City State utah zip 84104
lnstallatiory't pgrade lnformation
Tank #
lnstall/upgrade
Capacity (gallons)
Type (FRP, Steel, etc.)
Substance to be stored
Piping Type (Press., Suction, Gravity)
Tank Leak Detection Method
Line Leak Detection Method
Form of Corrosion Protection
Spill device to be installed (Y/N)
Overfill device to be installed (Y/N)
25.000 oallons
1
uporade
steel
diesel
suctaon
Veeder Root TLS 350 to be installed
deferred
lmoressed current svstem and interior tank lininq to be installed
Y
Unusual or extenuating circumstances expccted:Temporary day tank (2,OOO gallon convault) for fuel storage.
Tank used for emergency power generation and boiler heating. Cathodic protection system disigned by Joram Lichtenstein, p.E.
I$CE Corrosion Sp""tg!ltt): C.P. System to be installed by Troy Spackman (NACE Corrosion Technologist). lnternal tank inspection
and installation of tank lining to be performed by Gatway of Salt Lake City.
-,,9i("o'p.tedf
orm'"'HlJ,l,3f
1?H;i]:"*flIil"ffi :11111*il","oi",ion
I68 North 195O West, l st Floor
Salt Lake City, Utah 841 16
State tCao Only: Date Rec'd Rec'd By Notice Sent To O/O
'}-'
I
/
!
i
^
lofl.ER tooia
N,
FIGURE t S|TE MAp, McKAy-DEE HOSP|TAI
wEt ltt+t cAD
-
UST lnstallatiory'tlpgrade p66it I
[ ] Permit Modification
lnstrllationCompeny WasatchEnvironmental.lnc.
Address 22zlo West California Avenue City
Phone # [phone]rtOO
Certified lnstaller's on Proiect:
Name Don Leach
Date work will commence
Facility lD# (if not a new facility)
Permit No. ; oc2 - |
€€lt Lake City State -!|1g!- Zip 84104
Cert. #
Cert. #
Cert. #
TL0O16 Exp. date 5/97
Exp. date
Exp. date
Tank Owner
Address 36 South State, Suite 23OO City Salt Lake City
[ ] lnstall/Replace
state JIg!-_ zip 84111
{€011442-4928Contact person
Facility ileme
Roser Mackev phone #
I X I Upgrade
Address 3939 Harrison Boulevard City Oqden State Lftah Zp 84409
contact person Scott Anderson phone # lgoll 625-2077
Tank #
lnstall/UDorade uoorade
Caoacitv {oallonsl 25.OOO oallons
Tvoe {FRP- Stael ate I steel
Substance to be Stored diesel
Piping Type (Press.,
Qr rarina l'!rqrritn suction
lnstall/Uoqrade What?
(Tank, Linis, C.P.,....)
tank linino and
C.P. tank-and
linec
Tvoe of lndrltmioMroonOe fiiXiil*#**::f,?tr1ffi#ijiiii
Descriotion: lnstall overfill, oversDill, tank monitor device, retrofit imorassed crrrenr Number
cathodic prot€ction for tank & lines and install intorior tank linino_1
Total lnstallation Tank Fee/permit +>r)o-
-
Unusual or c)Getturdolt carcumltrncer ereocbd:
$
Michael O. Lravitt
Govcmor
Dianne R. Nielson, Ph.D.
Erccutivc Dimtfr
Kent P. Gray
Dirct8
1 /-\
/3.r- n
. :i - i '
DEPARTMENT OF ENVIRONMENTAL QUALTTY
DTVISION OF ENVIRONMENTAL RESPONSE AND REMEDIATION
168 Nonh 1950 West
P.O. Box lzl4840
Salt l-ake City. Utah 84114-4840
[phone] Voice
[phone] Fax
[phone] T.D.D.
tzcrk)?o
Facility ID.# I C(})rzz-22-
Enclosed
/(
is the information you have requested regarding:
Tank Notification Form
Tank Closure Plan
Tank Closure Notice
Certified Tank Installers and Removers
State Certified Labs
Certified Tank Testers
Certified Groundwater & Soil Samplers
PST Fund Information
K other lfrr- Lr// /ev-rit
Utah UST Administrative Rules
UtAh UST ACt
EPA UST Regulations 40 CFR 280
Billing Information
ReleaselLeak Information
Musts for USTs
Dollars and Sense
Leak Detection Information
If you have any questions, please contact me at [phone].
@
Underground Storage Tank Section
Printed on recycled paper
F:\ERR\SUPPORnUST\FORMS\BLANK.F RM\SPMEMo
@
Michael O. I*avitt
Govcmor
Dianne R. Nielson, Ph.D.
Exccutivc Dirttr
Kent P. Gray
Dircctor
*
4
tn
, l" ,"tl i '-!- ./'r Uq4 : i.iy 4
DEPARTMENT OF E}.IVIRONMENTAL QUALITY
DTVISION OF ENVIRONMENTAL RESPONSE AND REMEDIATION
168 North 1950 West
P.O. Box l448rt0
Salt llke City, Utah E4l t44840
(801) 536-4Iffi Voice
[phone] Fax
(801) 5364414 T.D.D.
Date, K-272o
Dear Underground Storage Tank Owner/Operator:
The Division of Environmental Response and Remediation
From,Ll. llk.
will be ( installed (G-"4@"t
_ (facility D# lzce9a ).
received notification that one or more
underground tanks (USTs) (
Before'regulated receive deliveries of fuel and bb put iirto operation, they must qualify for the
Petroleum Storage Tank (PST) Fund and receive a Certificate of Compliance. To qualify the tanks for the
Fund and receive a Certificate of Compliance or maintain your current Certificate of Compliance, you must
do the following:
1. Register the changes in the tanks using EPA form 7530-1., Notification for Underground Storage Tanks
(Enclosed). Tanks installed after December 1988 must have the following in place when installed: leak
detection on tanks and piping (including automatic line leak detectors on all pressurized piping), spill and
overfill devices, and corrosion protection. The Utah Certified Tank Installer must sign page 5 of the form
to certify a proper installation.
Only: Complete the PST Application (yellow) and Previous Pollution Incidents
from the enclosed PST Fund application packet. You must indicate on the PST Application
type of financial assurance you will use for your share of eligible cleanup costs for each release
by the Fund.
3. Conduct a tank and line tighhess test and send a complete copy of the results to the DERR. The tightness
test must be conducted by a U. tah certified UST Tester for any new tank, line or system installed.. A list of
certified UST Testers is included in the PST Fund application packet. All portions of the tank and piping
system which could contain product must be tested.
4. . New pnkfor Systems Only: Pay UST regisnation fees and PST Fund fees for all new tanks installed. These
l/, Fregistration fee- $135 per tank; PST Fund fee- $250 per tank. These fees must be paid before an ffCerrrficate of Compliance can be issued.
New Tanks or
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eql 1u UUSC eql ot queuled aa; {uu prru'slFseJ 1se1'suuo; aql Puas 'galalduoc eJu sluall e oqB eB ueq/U[
UNDE. ,ROUND STORAGE TANK PRO- -TAM
Adiushnent Tracking Form
OWNER:Date: lzlTn f ,
Faciliry#: lbooq
epnnus
Yvww tn 81 tzs
Reason for:
(cirde one or more)
REFUND DELETE CHARGES Re-bill _Yes_No
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INSTALI"ATION INSPECTION
€lq
rnsra 11 Date tt 1a - q ?Inspector J,
Inspector Cert#-i aaQ?l_
owner only vr"r,*lproperty I rron"rry onlyI rTank
G. AuTf,,n,uif^,1, 4,,,!lt 1o,. l,,ny''
f-]tJ tank/Business
Street:
Tank Location
Name:
Street:
CitY:
Phone:
L
co*punyi r;t;
Tank Infornatron
original #Tank I - Removed Tanks
County zLp frttr/ a ?
cert.# TtCt/14
CapacitY
Substance
Type: FRP, Steel
witn cP, comPosite
lrew or Used't/t cr)
*Note: Used tank must be recert,ified by the nanufacturer before installation'
SeIf insurance... """Exp. Date
)...Commercial Ins. (
Risk Retention GrouP "..""
Guarantee....
SuretY Bond """'
Letter of Credit """"o"'
3rd PartY Liab.
+ Neu Tanks / = current /
J.(onilosrU
D suoo* E st"t,fJ gruir E srrt1
Other
AMT. REQUIRED bY Date:
Per Occurrence:
Total
Aggregate:
FacilitY ID No.t2.o,rrlqd
Pre-fnsta Ilation YN
Is the equipnent adequate size to lift and lower tank? Y
HasavisuaIinspectionofthetankbeenmadechecking<for scratches and other damage?
If the tank or piping has been danaged, have repairs been
made.
Has the tank been air-tested at 5 PSIG (3 PSIG for all FRP
except Owen; Corning) while applying soaP solution 9l:o Xseami and fittings to check for leaks and found tight
Has the piping been air-tested at 15Ot of operating
pressure for i hour -5--
fs the excavation free of aII debris?
Is the excavation area subject to traffic?
Has sufficient depth of the excavation been allowed
taking into consideration traffic, ground-vater-
condiiions and piping runs with Llg" per foot slope back
to tank?
If anode, .has it been checked to see and have the
plastic wraPPer has been removed?
Backfillinq
Has aE least one foot of nackfitt naterial been allowed
to act as a bedding material for the tanks? Depth-rr '
Type of bedding and backfill:
Er." Grave1 (Ll8" to 314" size)Ectr=ned Rock(1/8" to Ll2" size)
I
"1""n washed sand E o.n.t
Has the backfill been compacted to ensure full support
along the tank 5 & 7 o'clock points on the sides?
Anchoring
fs the excavation subject to ground water?{
rf so, Method of Anchoring, EDeadman nr"u n o',r"tburden
other
Y
x
A/+
Are the hold-down straps in place according to
manuf acturers sPecif ications?
I Facility ID No.
fnsta I lat:on
Discance from Tank(s) to Nearest Property Line(5tnin. ) :...
Dj.stance fron Tank(s) to Nearest Structure3...............(5' plus 45o from surface to tank)
Estinated depth to Ground Water:........ o.................
Do tanks have at least 18'f spacing between tanks?(stable conditions)
If unstable walls, are tanks spaced at Least Llz timesthe diameter of the tanks from each other?
Does depth of installation conform to planned Anchoring,
Surface and Traffic conditions, ground water conditions
and piping run slope requirements?
Has Tank and Piping Cathodic Protection systems been
checked to see if they are working properly?
Does the amount of Tank Deflection meet specs.
Type of Spill and Overfill control:
Type of Pump System:
F or"==rrt"Common Suction n r.r.r suction
Type of Piping:
ft.
ft.
ft.
Y
,U+
I
\
I
I
--1-
t+
i
D r*,
Type of Release Detection for Tank (at tine of installation):
F aroundwater Monitoring
E ao"a.O Steel with Cathodic Protection
E orraoratic Tank Gauging
E roil Vapor Monitoring Drirnaness Test with rnventory
E rna"rstitial Monitoring F
".r,,r"1 Tank Gaugingr o.n..
Type of Release Detection for Piping (mark all that apply):
f] rinnaness Test (Annuar-Pressure)I
".orndwater Monitoring
f] roit vapor Monitoring f] ri.nnaness Test ( 3yr-suction)
I rr,a..stitiaI Monitoring n*or,"(Safer Suction system)
f] rcux Detector n o.n"t
ictui, llu, 5, '''(.
If any of the above is contrary to proper installation procedures asoutlined in the manufacturers guidelines or other guidance, please explain
what and 'shy: -__i_'faorL ,'5 {cr 'e rv,-r t, ' "'c",' I " /,u t tt(.o /'
^
Drawn By
STTE PLAT
Date:ID No
t{
l.
Llnes: -s-s-s- - Seuer;
{-t{-w- -l{ater;
ilonltoring ttells (lltl-#, Vhl-#, PZ-},
Sample Loiatlons. (SS-#. brs-#. VS-#' AS-t)
Bore Hole (8H-r)
- Water tlells (donrestlc, llvestock, etc.)
Pouer; -t-t-t- . Telephone; -g-9-9- - GiSi
French [}rains;
Euilding, etc. outllnes
Tank & Line outllnes
Potentiometric Surface
Creeks, Rlvers
Q=l=t:
tr
-p-p-p-
-d-d-d-
,{,
FACILITY ID.
PStr PROCESSTNG CHECKIJIST
Year F\q{
rzoO4 O
UnaccepE.able NotAcceptable Applicable
Non-Marketer DiscounE
)<Previous PolluE.ion fncidenE,s
\rlt4 lq Ll- LUST File @u t&, {a^-k- Eorm rncluded 9N _
rrr u - *l*b^p
- rlerify rank/lines ltlz$lo,L/
@Nd
@zN
@n
vs registered
Document.ation ok?
Rate ok?
-FY91 Or_!Li@-FYe2 01@
Fund Paid
- FY 93 Ql_-FY94 O
t2-122-lx\
$o
t\ 6q ya-sH)
Y/NFees Paid
-FY88
-rY89-FY90-FY9L_FY92
-FY93-FY94
vzlr2low(p"
T'{ 4{ -re, (d3 O,q
Compliance
- Compliance OuE,st.anding?
- Leak det.ecEion reguired?- Spil1/overfiIl required?
- Corrosion proEect,ion required?- t'loLification up to date & complete?- Applicat,ion submieted?
q6
€/N@N
Q/N
GYN
Date Qualified
Dat,e Issued
Review compleEed and certificate issued by
pacproc.fril 07129193
Michael O. Iravitt
Govcmor
Dianne R. Nielson, Ph.D.
Exe.utive DiEto
Kent P. Gray
DLcctor
ffitm&m ffif, ilT&mfo
DEPARTMENT OF ENVIRONMENTAL QUALITY
DTVISION OF ENVIRONMENTAL RESPONSE AND
168 North 1950 West lst Floor
Salt kke City, Utah 84116
(801) s36-4r00
[phone] Fax
(801) 536-,1414 T.D.D.
TO: Dr'riqht Solomon, Dir. of C1in. Enq.Intermountain Health Care Corp.
451 W. 4380 S.. Buildinq CSalt Lake Citv. UT 84723
Enclosed is information regarding:
X Tank Notification Form
Tank Closure Plan
Tank Closure Notice
Certified Tank Installers X
Certified Tank Removers
Certified Tank Testers
Certified Groundwater & Soil Samplers
State Certified Labs
FACILITY I.D. # 12OOO9O
Date: 10 /78/94
From:Paul Hardino-'
Utah UST Administrative Rules R31l
Utah UST Act
EPA UST Regulations 40 CFR 280
PST Fund Information
Release/Leak Information
MUSTS for USTs
Billing Information
Leak Detection Information
Other:
Message: Dear Mr. Solomon:
storage tank at Mckay-Dee Hospital in Ogden.
forms, please contact me at (801) 5364100.
Sincerely,
If you have any questions or need any help in completing the
Printed on recycled paper
lUlSi/94 lo:O(hm
FacilitY lD #
PETROLEI,M STORAGE TANK FUND APPT.TCATION
Facility Name
Address 3939 Harri son Boul evard
City 0qden
CountY Weber
120090
State Utah Ap Code 84123 State Utah Zp Code 84409
va5.v
ehrrna [phone]I lavlrv
Contact persel Dwight Solomon
Phone [phone]
Contact Person Douq Garmeyer
TYPE OF OWNER
iT-;mt"r, or non-marketer with facility average monthly throughput g_r_eater than 10,000 gallons.
i X j f.fon-marketer with facility average monthly throughput less than 10,000 gallons (must verify).
DESCRTPTION OF UNDERGROUND STORAGE T4NKS
Tank# 1 3
Aoe 1968 1994
Cipacity 25,000 500
Substance Diesel Diesel
TANK NGHTNESS TEST
Tank# 1 3
Pass/Fail Pass Pas s
CERTIFICATE OF REGISTRATION
@StorageTanks(USTs)atthisfacilityhavebeenregistered.i X l All tank registration fees have been paid.
CoMPLIANCE WlrH UST REGII,LATIONS -
iliancewithallFederal,State,andLocalUSTregulations?
t- X I yes [ ] No it 'No' please describe item(s) of non-compliance:
PREVlous PoLLUTION INCIDENTq
ftas a potlution incident ever occuned at your facility?
1 X I Ves lf 'yes' please provide LUST (Leaking Underground Storage Tank) information:
discovered and replrted-l rly dis f. see Tetra
-ch
report.dated June 15, 1994.
t 1 No tf 'No" please attach-a letter stating that under customary businessjnventory practices standards
you are not aware of any release from any tank(s) at this facility. The PRflIOUS POUUflON
INCIDENTS form maY be used.
INDEPENDENT FINANCIAL ASSURANCE
ail have met the financial responsibility reguirement for the first $25,000 per release by the following
method:
lGuarantee [ ]Commercial lnsurance [ ]SuretyBond
I Letter of Credit [ ] Other
ceftifl under PenattY of made by me are true and correct.
X] Self lnsurance t
I Risk Retention GrouP t
Owner/OPerator
above
Date signed / 7 lctou /4c/4
I Facility lD #1200090
.l
I This tetten or an equivalent, must be signed and induded wih pur appliation and faes.
PREVIOUS POLLIMON INCIDENTS
Mr. Kent P. GraY
Executive Secretary ruST)
Utah Sdlid & Hazardous Waste Control Board
signature of owner/oPerator
E
t have had the following releases of petroleum (detailed below; also mention any action you took to clean up
the release).
Failure to report previous releases could void your covemge under the Petroleum Storage Tank Fund.
pQ9fir
To:
Dear Mr. GraY:
As required by paragraph 19-6413 of the Utah Underground Storage Tank Act, I have performed a tank and
line tightness iest on each underground storage tank at nry facility, and based on this test, there has not been
a relelse of petroleum. Additionally, based on 'customary business inventory practices standards' I am re!
aware of any release of petroleum from my tanks.
LUST Des'ignat'ion-EINI During remova'l and replacement of 500 gallon usr #2' d release
discovered and
Tetra Tech report dated June 15, 1994.
-
n
St
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***H-,
8emcn"
tq$', *, /q,t
Potlo Toch, lnc.
11170 Sandy Gulch Road
Sandy, Utah 84094
Phone [phone]
Fax [phone]
hffirrrlLI€rE rc
}TCKAY-DEE HOSPITAL
3939 HARRISOT BLVI'.
oGDElr, urAE
T'}TDERG'ROT'ND STIORAGE TAIIK AlfD LIITE TESTIIIG
TESr IiIO. 941109
tr;\
#&ffi 3Hffi-.J
Srnncn"
Peto Tech, lnc.
1 1 170 Sandy Gulch Roao
Sandy, Utah 84094
Phone (801 ) 572-9303
Fu(801)571-8975
r mdsd'tfitx,&LrElB7/tfi
Test No.:
Test Date:
Test Operator:
Utah Cert. No.:
Location:
9411-09
November 9, L994
John Labrum
uTo0L48
McKay-Dee Hospital
3939 Harrison BIvd.
Ogden, Utah
CERTIFICATTON
TAI.IK TEST REST,LT
Product
Waterfn Tank
( Inches )
Hiqh Level
Leak Rate
(GPH)
Low Level
Leak Rate
(GPH)
FuI1
System
fncluding
Vent Line
Tank
Only
0 Less than .050 N/A
PRODUCT LINE TEST REST'LTS
PunP TYPe
Pass Pass
Results
DieseI
Product
ITATER LE\IEL CONSIDERATION
The test of the above tank systems is considered sufficient for certification
DurDoses since the water l6ve1 in the backfill area is below the point of
[;a;;;i;ti.c equiiirrim on any portion of the tank or piping.
Diesel Suction Pass
PETRO TECH, rNC.
^
l-..,.. r* a l< (} r: m t= r: u r= rffi Gl lr( PA6E
Tes't Number : A:'74ll@')?.'7 -A0B
L_ o o k Ft e 3:r t::r .r-" t;lck1.)
[:tJ[? :
t-.{l(lA t- I0N :
DAI-li:i 0[: lh-51':
t..-[:AK {--t]llpuTHR
55O gaI lrrn DIt::3h:1..- fank
3939 l-lAl?[?ISON, t]GDt'.N, lJl-Al'{ '
I L /O9 /'.?4
s,/N: fg@@?Otw
-lest l...evel Ot3 tnches ABllVl;: l';lnk l-op
D;rta frrrm llhannel A
t'lan i. l=r: I rJ i ng : Nt:ne(:OE: O.O@O4A@ Sper:. Gr. = A.B?' ]'ank ft:mp: 5'l '?
l..r:ak Rate Average r:l' 3@ (lyr;lers
T,t a 1 'Test T j. me : l:35 hours .
-[tr$.L-B!:"$!J]*-Is.F];itl Avr:rase Lreak llai;e: less than b .@5 gnllhr '
llate r:f l"empr:rat,rr'* ,rhan{J,t, -O-OOO9 deg l:ltrr '
Rate ol' Volume r:hange; O.OOZA gal/hr -
O.99 Errr:r Banr.Jr 1-/- O.OO gal./hr.
]-ank ;rnr:l Syr:tem: TIGHT Q Ot3 inches Aft]OVH lank l'r;lp '
Test Ter:hnici;rn:
i,
It. --.
f.-
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0 .50-e.5
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L-r=ak Comt=r-rcer$ Glr-tLck [-rpr=k Fter=c:r't( rIA(iE 2, )
Test Number : A :94 t lO'?27 .fiOB
Leak Rate - 6AL/}|R
{}ne l}ivision = 0.10 gal/hr.
Dashed I
Represent +l-
ne8
0.05 sal/hr.
8: 13
50
9: la
-c.
I
I[ LEA|(
Dar rhad
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l-es:t Nrrmber:A : ,7,l' l.lu.t';1"7 . A0l3
l::tJ1i: 550 uallon DI[:.S[:-|.. l';rn'k
I t)[A f I ON : 3939 l{Al?li I SON , 0(iDI-:N , tJ]"Al-l -
l)i'rll.: (lF l'Ll$]': I|/O9/'?4
t..l.iAK rlgyptJl-t:t? S,/N z .tgo@?rbIe
'l'esl; L.eveI Ol3 [nr:hes rtBOVt: l'ank l"or)
l)ata frr:m Channr:I A
Man I l"r: t rJ i ng: Nrrnt:
C{)t:: O .AOO4AO Sper: . 6Y . z @ .B? l-ank lemp: l:4 ,'/
l..eak R:ttr': Average r:f 3O G/r:Lrarr
l-ot a I Trasst l- i. me : l:35 hours .
rr.$-L_ R[::iul","]:$
[:inat Average L-eak llai;e: tess than b.@5 gal/hr.
ll;rte of l'empr':ratrrre change: -O"OOO9 deg l'lhr.
Rate ol' Vr:Iume r:hange:. O.OO?A gaL/hr .
O.99 Errrtr Banrl2 i-/- O .OO gaI./hr .
'l'an k anrj Syr:t em : l'I GHT 0 On i nchr:r: ABOVI:: l-arr k 'l'r:pr .
l-est Ter:hn i r: i an :
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Test Numher z A:,ti tle,?;:'7 .AIit)B
i
t
Leal Rate - 6AL/HR
()ne 0ivision = e.l0 sal/hr.
I
I}I LEAI(LEAI(
Daehed Linas
fiepresent +l- 0,05 gal/hr.
-0.5
6: l2
T
I
11
E
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8: 13
?: ll. -e.
i
Results of U.S. EPA Standard Evaluation
Volumetric Tank Tightness Testing Method
This form tells wherher the tank tighrness tesring method described below c.omplies with tl:e
p.riorn-,once requirenrents of the Federal underground storage. tank regllation. The evaluatiott rvas
ton<iucte6 by thi equipment manufacturer or a ionsultant to the manufacturer according to -the
U.S. EpA's ;standr,licl'I'est Procedure for Evaluating Leak Detection Methods: Volumetric'[':ink
iighrnlssfeitilg Methods." The full evaluation repbrt also includes a form describing the method
anri a form sumtnarizing the test data-
Tank owners using this leak cletection sysrem shoulcl keep. this form on.file to prove cornpliartce
rvit5 tlre federal rJgulations. Tank o*ners shoulcl check with State and local agencies to makc sure
this form satisfies their requirements.
Method DescriPtion @r* Test systernName LEAK COatIPtllrER
Version
VendOf Hasstechr fnc'
5350-E B"=tg"tt *I1
=_=.san Diego -""'* 92121 619-457-5880
Evaluation Results
This method, which declares a tank to be leaking *!qn the measured leak rate exceeds the
rhreshold of o.ou'J;ron prr nour, nas a pr-ooaoirity of false alarms [P(Fn)] of s %.
The corresponding probability of detection tP(D)l of a 0.10 gallon per hour leak is 95--"t"
fB;,,3,"'3,0,fl?=tfiLti3o=E[338r'tbo., not meet the rederat perrormance standards
estabtished by the U.S. Environmental Protection Agency (0.10 gallon per hour at P(D) of 95% .
and P(FA) ol 5%).
Test Conditions During Evaluation
The evaluation testing was conducted in a 8,099- - gallon C steel D fiOergtass tank
in.i *., lt- inches in diameter and 2s5's inches long.
The tests were conducted with the tank 100 percent full.
The temperature difference between product added to fill the tank and product
already in the tank ranged from +op 1s -1 .8 oF,
with a standard deviation of ' N/A oF.
The product used in the evaluation was
Volumetric Tfi Method - Results Form
Gasoline
Page 1 of 2
Method J ".*u*-Qr* rest systan
Version
Limitations on the Results
The performance estimates above are only valid when:
. The method has not been substantially changed.
. The vendor's instructions for using the method are followed.
. The tank is no larger 163n 20,000 'gallons.
. The tank contains a product identified on the method description form.
. The tank is at least 100 percent full.
o The waiting time after adding any substantial amount of product to the tank
is at least 0 hours.
The temperature of the added product does not differ more thanN/A degrees Fahrenheit from that already in the tank.
The waiting time between the end of "topping off," if any, and the start of
the test data collection is at least o hours.
The total data collection time for the test is at least variable hours.
Large vapor pockets are identified and removed (for methods that overfill the tank).
This method E can n cannot be used if the ground-water level is above
the bottom of the tank.
Other limitations specified by the vendor or determined during testing:
ability to detect leaks. lt does not test the equipment for salety hazards.
Certilication of Results This certification made in accordance with the U.S. EPA
I ce rtry th at th e,o r u m etri cfahkfi g?fth* roP&r irig3 h 3 fl ?8d k5tssB#&e d ac c o rd i n g t o t h e
vendor's instructions. I also certify that the evaluation was performed according to the
standard EPA test procedure for volumetric tank tightness testing methods and that the results
presented above are those obtained during the evaluation.
Detlev E. Hasselnrann Risk Reduction Eqineering Ia.boratory
' -gg.onqtg5ntal- kotectiofi esency
201 -321 -6674
(date)
Volumetric TTT Method - Besults Form
Septernber 12, 1990
(phone number)
Page 2 ot 2
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. Print your name and b,-,ess on the reverse of this form so that we can
return this card to you.
. Attach this lorm to the front of the mailpiece, or on the back if space
does not permit.
. Write "Return Receipt Bequested" on the mailpiece below the article number
. The Return Receipt will show to whom the 6nicle was delivered and the date
delivered.
. Complete items 1 and^P for additional services.. Complete items 3, a '& b.
3. Article'Afldressed to:
bWra., Sorrp,ror.J
;-ffi*C, Xtsc..
{u t Wes, 4aYo $,,r*
Etdq C
g4 t23
ignature (Agent)
I alsor{sh to receive the
followin rvices (for an extra
fee):
1. E Addressee's Address
2. ! Restricted Delivery
Consult postmaster for fee.
4a. Article Number
P go/ blz t2,
4b. Service Type
LJ Registered
Pfoertifieo
l--J Express Mail
E lnsured
E coo
fl letur1 Receipt for
7. Date of Delivery
8. Addressee's Address (Only if requested
and fee is paid)
PS Form , December DOMESTIC RETURN RECEIPT
UNITED STATES PO9-qL SERVICE
\-/
Official Business
lilt
Print your name, address and ZIP Code here
UDEQ/DERR
til##i:h* s4,14-4840
&*$1
$S , ". "lg- nf" tlq**-- i-.s:,!l $i$,"1 1..3 ', .i i-,'u,", l.'{"-... \ j s 1" ,' }* { 'i i g
il
+ ONPERTUENT OF ENVIRONMENTAL QUALITY
FIL E COP Y
Michael O. lravitt
Govcrnor
Dianne R. Nielson, Ph.D.
Exccutive Directu
Kent P. CraY
Dir4tor
, nrvnroN oF ENVIRoNMENTAL RESPoNSE AND REMEDIATIoN
ti,
168 North 1950 West lst Floor
Salt take city, urah 84116
[phone]
[phone] Fax
(80r) 536-4414 T.D.D.
ERRU-374-94
CERTIFIED MAIL
RETURN RECEIPT REOUESTED
October 25,1994
Dwight Solomon, Director, Clinical Engineering
Intermountain Health Care, Incorporated
461 West 4380 South
Building C
Murray, Utah 84123
RE: FACILITY ID # 1200090
McKay-Dee Hospital
3939 Hanison Boulevard, Ogden, Utah
Dear Mr. Solomon:
The Utah Underground Storage Tank Act (Act), regulates underground storage tanks (USTs) and
imposes certain obligations on the owner or operator of a facility having USTs. The Act specifically
requires the owner or operator of a facility, with USTs, to meet the following requirements:
' Register the USTs. Pay an annual registration fee. Pay an annual Petroleum Storage Tank (PST) Fund fee
. Meet specific technical and performance standards. Meet certain financial responsibility requirements. Maintain adequate tank records. Participate in the PST Fund. Prec-ision test the tank and lines as a requirement to participate in the PST Fund
The Division of Environmental Response and Remediation (DERR) records indicate you own or
operare two (#l and #3) USTs, and owned or operated one additional UST (#2, removed on
March 28, 1994),located at McKay-Dee Hospital, 3939 Harrison Boulevard, Ogden, Utah.
Plnled on recycled paper
-\/
CORRESPONDENCE TRACKING SHEET
,r*o' tt 1? *?y'
*psrr>fl.1\.
';$r:ri 3'i ';' ';
er,nor, ?*;i [-f.^r.lM ?
Subject : tJx) u + l2-4Y)oqo
File location: F:\ERR\
Date submitted:
Attached enclosures:
Suggested
Mailing Date:
s""r"*y, 4A /%?
Certif,red: ,"r-/ no-
,/
cc's mailed: ves/L no-
Enclosuresanached: Ye,
Date Mailed:
Initials of person mailing:
.,tt-/.-b-Z '7u
Instructions:
FINAL APPROVAL
Date Initial
Secretary
Author ro-ts-11 PRHr
Section Manager /0-r'Arr--
Br,fgrr,h*@
Accounting/Legal Staff
Director Secretary fu--
Director (Date signed)r oLv fu-
,.,;
Facility ID# 1200090
Page 2
Information provided to the DERR indicates your facility is not in compliance with the following
requirements:
l. The DERR has not received proper notification for UST #2 (previously non-notified and removed
March ZB,lgg4), and #3 (new tank installed April l, 1994) located at the facility identified above.
Z. The DERR has not received payment for registration fees and interest, now past due for UST #2,
for rhe fiscal years 1988, 1989, 1990, 1991, 1992,1993, and 1994, and for UST #3 for the fiscal
years 1994 and 1995.
3. The DERR has not received payment for PST Fund fees, late penalties and interest, now past due
for UST #2, for the fiscal years 1991, 1992,1993, and three quarters of 1994, and UST #3 for
fiscal years 1994, and the first two quarters of 1995.
4. The DERR has not received a copy of a precision tank tightness test as required to qualify for the
PST Fund for UST #3.
5. The DERR has not received an application for the PST Fund or issued a Certificate of Compliance
to McKay-Dee Hospital for UST #3 located at the facility identified above.
In order to satisfy the requirements of the Act you must do the following:
rq(-
$[]4t2. Submit an updated notification form indicating tank and piping type, substance stored, and other
required information for USTs #2 and #3.
ah Submit payment for registration fees and interest, now past due, for the fiscal years 1988, 1989,
' 1) 1990, 1t91, lgg2, lgg3, 1994, and 1995, in the amount of $702.80'
a3-\ Submit payment for PST Fund fees, late penalties and interest, now past due, for the fiscal years\--l lggl,lig1,lgg3,lgg4, and first and second quarter 1995, in the amount of $904.21.
r zg\q\;\'"u--{. Submit a complete copy of a precision tank tightness test for tank #3.
,^cl$. Submit an application for the PST Fund and obtain a Certificate of Compliance for the facility
\f/lr'' identified above, containing tank #3'
The Act gives the Executive Secretary (UST) of the Utah Solid and Hazardous Waste Control
Board (Board) the power to enforce rules made by the Board by issuing Notices of Agency Action or
Orders. The Act, Utah Code Ann., Sections 19-6-407 and 19-6-408, also gives the Executive Secretary
(UST) the power to assess a civil penalty of $1,000 if an owner or operator of an UST fails to register the
tank, $1,000 for failure to pay fees within 60 days of due date, and assess interest on the unpaid balance.
Other violations of the Act may result in civil penalties of up to $10,000 per day.
U
This lefter will advise you that your failure to comply with the requirements of the statutes and
rules may result in the issuance of a Notice of Agency Action or Order and the assessment of a civil
penalty.
Please contact Paul Harding at (801) 5364100, should you have any questions.
Sincerely,
lg7*JPJ,L *-
Kent P. Gray, Executive Secretary (UST)
Utah Solid and Hazardous Waste Control Board
KPG/PR}Ucb
Enclosure
cc: John Grima, McKay-Dee Hospital
Craig Heninger, M.S., Acting Director, Weber/tlorgan District Health Department
iU
Facility ID# 1200090
Page 3
Michael O. l.eavitt
Governor
Dianne R. Nielson, Ph.D.
Exculive Dircttr
Kent P. Gray
Direttr
S$q,irf,# ofl LTtah
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF ENVIRONMENTAL RESPONSE AND REMEDIATION
168 North 1950 West lst Floor
Salt l.ake Ciry, Urah 84116
(801) 536-4loo
[phone] Fax
(801) 536-44t4 T.D.D.
FACILITY I.D. # 12OOO9O
TO: Dwiqth Solomon, Dir. of Clin. Enq.
Intermountain Healt.h Care CorP.
451 W. 4380 S.. Buildinq C
Sa]t- Lake Cit.v, UT 841-23
Enclosed is information regarding:
X Tank Notification Form
Tank Closure Plan
Tank Closure Notice
Certified Tank Installers
Certified Tank Removers
Certified Tank Testers
Certified Groundwater & Soil Samplers
State Certified Labs
Date: l-0 /L7 /94
From: Paul Hardinq
Utah UST Administrative Rules R311
Utah UST Act
EPA UST Regulations 40 CFR 280
PST Fund Information
Release/Leak Information
MUSTS for USTs
Billing Information
Leak Detection Information
Other:
Messase: Dear Mr. Solomon:
These are the forms that need to be completed and submitted as soon as possible for the new underground
storaee tank at Mckay-Dee Hospital in Ogden. If you have any questions or need any help in completing the
forms, please contact me at [phone].
Sincerely,
Pflnled on recycled PaPer
l0l7/94 l:52pm
TROUND STORAGE TANK PRG. rtAM
ility#: l^ 9-OonO
REFUND DELETE CHARGES
3- 2g- qq {\r,"11 ^
& z g::r)
Ftr q{
s tsc {
,) l.bfcr.
oz
III
o
z
$z< v fuf.
Y qq r tik-
$ \6+ il"|
! \q + .,U,r|.--
t l35 r ,'"k
A@unfJrt
(J5aADFTGEVE/10/9J)
a uNpERGRou tnaa o3/01/93r
Facility lD # 1200090
ENVIHONMENTAL QUALITY
JUI'J 2 0 tg94
DlV. CIF trf\ivl it0tJMEN"I"AL
HESPONSE Ariil g,;lf [llATtON
Closure Notice prepared at the request of the owner/operator (identified below) by Jack F. Mark
of (companyname)@ Phone#[phone]
Address 1555 West 2200 South€uite lB"City Salt Lake Citv State Utah Zip 841 19
FACILITY INFORMATION
Tank Owner McKav Dee Hosoital Phone#[phone]
I I dba (individual doing business as) [ ] sole prcprietorship [ ] partnership I X] corporation
Address 3939 Harrison Boulevard City lgden- State Utah Zap-84409-
Facility Name McKav Dee Hosoital
Address 3939 Harrison BoulM City-Qgden- State Utah Zip 84409
Contact person .lohn Grima Phone#[phone]
Number of regulated tanks at the facility before closure: two
Number of regulated tanks at the facility after closure: two ( The UST was reolaced )
TYPEOFCLOSURE I X] Permanent [ ] Temporary I I Change-ln-Service
[ ] Sludge was removed I I Tank was cleaned.
Samples in LUST File #,
Permanent or Chanoe-in-Service [ ] Fuel was emptied
Tankwas: I IPurged IX]lnerted. MethodUsed:1O nounds of rlrv iee
Location of Closure Records 3939 Harrison Boulevard
For in-ptace closure: tanks filled wi
Substance to be stored for Change-ln-Service
Temoorary [ ] Fuel was emptied. [ ] Corrosion protection is operating. [ ] Release detection equipment is operating.
Residue depth remaining in tank _ inches, or _% by weight of total capacity of UST.
3 months: [ ] Vent lines open
12 months: [ ] Permanently closed
Cap/Secure: [ ]lines []pumps I lmanways
[ ] New/Upgraded [ ] Extension request
. TA|UKS CLOSED
Tank #1
Age of tank 1986
Capacity 500
Subs. stored' Diesel
Date last used 9/93
Date closed 3128194
Rmvd/ln place Removed* lndicate the specific substance stored in each tank closed (regular, unleaded, diesel, waste oil, etc.)
TANK REMOVER Name Jack F. Mark Cert. # TRO182 Exp. dateTJl'U9tl
Company Tetra Taeh. lnc.Phone#[phone]
Address 1555 West 2200 South Suite "B' City salt Lake citv state_uEh zip_84-Ll9
SOIL/GROUNDWATER SAMPLER Name Jack F. Mark Cert. # GS0361 Exp. date 1/29/95
Company.Tefra Teeh- lne,Phone#[phone]
Address 1555 West 2200 South Suite "B' City-Se.ltLake Cj!y- State Utah Zip 84119
DISPOSAL SITES USED:
Tank: lntermountainStcel Date 3128194 Number 621-4563
Product from Tank: Advanced Petroleum Recvclino Date 3128194 Amount 90 oallons
Contamanated water from tank cleaning: Advanced Petroleum Recvclino Date 3128194 Amount 410 oallons
Sludger None Amount
Contaminated Water:Amount
AmountContaminated Soil: PAPPAS Brick & Stone Landfill Date
ls any contaminated soil which was overexcavated still on site?Yes X No Not applicable
SITE ASSESSMENT
Complete the Facility Site Plat (Closure Notice) and Sample lnformation 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 lD # on the site plat, table, and lab analysis report.
t X I Completed Facility Site Plat (Closure Noticel is attached.
t X I Completed Sample lnformation Table (Closure Notice) is attached.
I X I Certified lab anatytical environmental sample results are attached.
I X I Unified Soil Classification (USC) sample results are attached.
I X ] Chain of Custody form is attached.
Sampleswere properly: t Xl Cotlected t XI Labeled t Xl Packaged t XlTransported
t X I Samples were in sight of the person in custody at all times or in a secured locked place.
t certify under penalty of law that the closure site assessment at this facitity was conducted in accordance with R31 1-
202 (parts 280.52 and 280.721 and R31 1-205 U.A.C., and that any additional samples required by R31 1-202 patts
Date
Date
28,0.52 and 280.72 and R311-2O5-2lall1) were properly
Signature of Certified Groundwater/Soil Sampler
Full name of Certified Sampler Jack F. Mark
,r/,
Date S/zs/ l4
-
,, ^ FAclLlrY slrE PLAT (cLosuBE Nor^!
ihe s;te plat must show locationr .,rf atl buildings, streets, property boundar*s, tanks, piping, dispenser islands, and
underground utilities. The site ptat must be drawn to an appropriate identified scale. lt must show actual sampling
locations, substances stored in tanks, and other retevant information. Tank and sample identification numbers must
be consistent with the information given on p. I and 4 of the closure notice.
= Sampte locations (SS-#, WS-#, USC'#)
= Monitoring Wells (MW-#,)
= Soil boring (B-#)
= Water Wells (domestic, livestock, etc.)
x
a
o
o
3
Facitity tD #j3g9o99- Drawn Bv Dennis Riding DateW
WELL
EXCAVATION
U.S.T.. (nruovED)
.ss \\_,s
SYMBOL SAMPLE NO.
A RM-2
A RM-J
A RM-4A RM-s
SYMBOL S,AMPLE NO.
A ss-1, GW-1A cw-zA ss-3
A RM-l
\
\
U.S.T. PIPING
*SlnY -''-
Bug)-
.icel
Complete table for att samptes that w-ere taken for ctosure. Sample tD numbers on the tabte must be consistent with
the sample lD numbers given on the site plat and in the lab analysis report.
Sample # Sub. stored Spt. typer Depth2 Compounds3 Analysis method(s14
in tank
SS-1 Diese! Soil 5'6" USC
GW-l Diesel Water 6 feet TPH. BTEX
GW-2 Diesel Water 6 feet TPH. BTEX 8015 Modified- EPA 8020
SS-3 Diesel Soil 3 feet TPH. BTEX. USC 8015 Modified- EPA 8020. ASTM
RM-t Dieset Soil 5'6" TPH. BTEX 8015 Modified- EPA 8020
RM-2 Diesel Soil 5'6" TPH. BTEX 8015 Modified. EPA 8020
RM-3 Dieset Soil 5'6' TPH. BTEX 8015 Modified. EPA 8020
RM4 Dieset Soil 5'6" TPH. BTEX 8015 Modified. EPA 8020
RM-S Dieset Soil 1 1 feet TPH. BTEX 8O15 Modified. EPA 8020
, soi! (ss), Groundwater (GW), or Unified soil classification (usc).
2 Final depth (in feet) below grade at which samples were taken'
' Contaminant compound(s) analyzed for each sample (TPH, BTEXN, O&G, etc)'
a Appropriate analyiis methods for contaminant compound(s) in each sample (801 5 mod., 8020, 413' 1 , etc)'
-State Certified Laboratory used: Utilitv Testino Laboratorvta;-;;;.:: nis s.,,,tr, chestnut Street City Salt Lake State Utah Zip 84125Address gZS Soutfr Cnestrut Street City Salt Lqke State Utah Zip 84125
Contact psrson Don Thorsen Phone#[phone]
-State
Certified Laboratory to be used: ENVIROPRO Laboratories
Address 1600 West 2200 South Suite #104 Citv Salt Lake State Utah Zip 841 19
Contact person Prrr{r; I lhhen - Phone # l8O1 | 974-3114
ptease explain any unusual or extenuating circumstances encountered during the site assessment or closure:
I certify under penalty of law that ! am the Owner of the tank(s) described above and that I am familiar with the
information on this form and that it is true, accurate and complete and further, that the procedures described herein
y/-were followed during tank closure.
Signature of UST Owner
ASTM D24IJ8-9U
8O15 Modified- EPA 8O2O
Full name of Owner
Return completed Closure Notice Facility Site plit and Sample lnformation Table, Soil/Groundwater sample lab
analysis resutts, USC sample resutts, and Chain of Custody form within 90 days of UST Closure to:
State of Utah Dept. of Environmental Ouality
Division of Environmenta! Response and Remediation UST Section
150 North 1950 West 2nd Floor
Salt Lake City, Utah 841 16
oate -/ ,/y'-?q
4
ENVTROPBO LABORATORI ES
E nv i r onmenta I AnalYsl s
1600 W€sl220o South, Suile 104
West ValleY CitY, Utsh 8t1119
Phone/Fax 974-31t4
CERTIFICAIEE OP ETEL?SI S
CTIENT: EETBA TECB
;aa;;;":-riss nist 22oo south' suite B
Salt Lake CitY' Ut' 84119
Date Received : 4-1-1994
Project: IHC HcKaY Dee
ATE.LYSTS BE5UI,!S:
Anal rsis
Tota1 Petroleun
Hydrocarbons
Lab Samole I 'D
0 91001
Ataalvsis Hethod
er Samale f'
RPR I I '94 B: 83 FD'1\ TETRR TECH i PRGE . AA3
CONIACT:
Received
Jerry Riding
By: RudY Labban
California dePt' of
ieafth 8015 mod'
contaminated
Dal.e Analvzed
4-1-r994
Sample ID
0 9r001
9.A/9.c REPOR?:
SP-I StockPiled
Soi I
Detection limit
nql I
GasoIi'ne 10 . O
Diesel2 L0.O
Sample
concentration
ME/ I
<r0.0
s26.3
sPrKE RECOVERY/DUPLICATE RECOVERY
0 910 0l 09100I Dul I rrcor:rt
coutrol lidts
<10. o
s45 .1 t03DUPTJICATES+/- 20t Gasoliae
tl- ?0t Dirsel
<10 .0
s26.5
E N v r E o B[3*j]ngBfro R I E s
1600 West 2200 South, Sulte 104
west VatleY CltY, Uu$ E{tlg
Phone/Far 971-9111
CT.IEI{T: IEINA lEH
Address: 1555 l{est 2200
Salt talte city,
Ete Received: {-1-1994
Project: IHC l'tcKay Dee
T.TAETSIS RESOf,TS:
anal vsis
BTEX
r.ab Samd.e-I-J'
0 91001
ANALYTE
Benzene
Toluene
Ethyl benzene
tylenes
Naphthal ene
RPR II '94 B:24 FN' TETRR TECHv PAGE.AA4
South, Suite B
ut. 84119
EPA 8O2O
Customer SamPle I-D
sP-1
@DmACf: JerrY Riding
Received EY: Rrdt L,abbar.
AnaIvsis Hethod
EPa 8020
Late Analvzed
4- 3-1 994
DESECTION
ms/ I
.200
.200
.200
.200
.200
SA}lPLE
CONCENTRATION
mE/ I
<.200
< .200
< .200
< .200
2.85
LI}IIT
arralyzed value t recweryg,BBCIE ccrrtrol limits tnre value
8. 63 86lrif i uoroLoi uelc +/ - 20t 10 ppb
I,AB DI
RUDY LABBAN
olira 4'L(A4
ENVIROPBO LABORATOBIES
Envlronmenhl AnalYsls
1600 West 2200 Soulh, Sulte 104
West Valley CltY, Utah 84t19
Phone/Far 974'3114
CER IPICA:TB OE ATELYAIS
CLIET{T: TETB"A TECH
i;;;;": 1555 iest 22oo South' suite B
salt Lake Cit'y, ut' 84II9
Date Received: {-I-I994
Projeet! IttC l{cKaY Dee
AI{AI.IEIS 8ESUtr'fS:
Aaal vsis
Benzo(a)PYrene
Lab Samole f.D
0 e t00l
AnaI vgis UelheC.
EPA 58846 8270
sP-I StockPiled
Soi I
Detection lirnit
n.E/ I
IPR 1l '94 BtAA P O;.\ TE TRR TE CH PRGE.AAS
CONTACT:
Recei.ved
Jerry Riding
8y: RudY Labban
costaminated
D^te Analvzed
4- 4-19 94
SamPle ID
0 91001
Benzo( a)PYrene
Sampl e
concentration
m9/ t
< .052
/-)
LAB D'RE c,roR (,fi\-{ (1fu'l
.052
R,UDT LAEBAN
ollre 44- %
RP
R

I
I
'9
4
:
B:

85
FO
C
TE
T
R
F

TE
C
H
Pn
G
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.

AA
6
Bl)Ill
-I.3lr$!cBi.BtT()c.Elr$To$E5iE0E-Tt
oot?NotzE3(,I,.
*
,
ooFo=(,
ILoz<-o
?(DIrOf\
'o-o@xlL
<a
HEA,LT-H DEPARTMENT
E. Mart Nldrols, MD. MSPH. Dlrector
Environmental Health
Roger C. Wilde, Director
2570GrantAvenue, Ogden, UT g4401
[phone] FAX: (S0t) sg9-Bgo8
March 18, L994
I{r. ilohn Grina
McKay Dee Hospital
3939 Harrison Boulevard
Ogden, Utah 84409
RE: Closure PIan approval for Underground
3939 Harrison Boulevard, Ogden, Utah
,HI,H,,*hr$[itt-J^:'[''
IIAR 2 3 tgg\
-J-'J. ff5 Ji''{ lf,H I}:: i'!'li* n
Storage Tanks (USTs) at
Facility Identification No. 1200090
Dear Mr. Grima:
The Closure Plan for the above-referenced facility, received by the
tfeber-Morgan District Health Department on March 16, L994, has been
approved subject to the noted nodifications, if any. This
department and the local fire department nust be notified 72 hours
before beginning closure activities.
Our records indicate that your proposed tank remover certificationexpires within four nonths. Please ensure that your certified
remover has a valid certificate during closure activities.
Any proposed change to the approved Closure PIan must be submittedin writing and approved by our office before implenentation. Ifcontamination is suspected or found during closure activities, youmust report it to the Division of Environmental Response and
Remediation (DERR) at [phone] within 24 hours of discovery.
Enclosed is a copy of the Closure Notice form which must be
completed and submitted to the Executive Secretary (UST). Pleasesubmit the environmental and Unified Soil Classification (USC)
sample analysis data and Chain of Custody forms with the ClosureNotice as soon as possible, but no later than 90 days after tankclosure.
If you have any questLons pleaee contact Joseph Decaria, of ttre
Ifeber-l,lorgan DLetrlct Health Departuent, at 399-8381.
SnectfurlY, , A(."^ L uJul-
nogeL c. Wilde, RS, Dlrector
DivLELon of Environuental Health
and InJurlz Control
RCI{/HS/sn
Enclosures
cc: Divlsl.on of Environnental. Response and Remedl.ation
Jack F. l,tark
,1
UNDERGROUND STORAGE TANh -OSURE Pi-AN (rev. 03/01/931 FAT- -TY !D#/.2 rn n 9b
i"".iJ"iffi3li:fl{fl-'-*:
Closure plan prepared at the roquest of the owner/operator (identified belowl by
(company namel Tetra Tech. lnc. Phone # ( 801 I 975-9091
Address 1555 West 2200 South Suite 'B' City . Salt Lakp Ciw State-Uleh- Ap 84119 '
A Contractor may prepare this Ctosure plan ,as tt e owner/operator's agent. ln preparing the Closure Plan, the
Contractor must act with the owner/operator's knowledge and approval; Rt owner/operator must sign the Closure
ll.l..,o,u,"Planissubmittedincompliancewith-ffi**Rg11.2o2SubpanGandR311.2o4(u.A.c.r $ARZ3 1gg\
FAcrLrw TNFoRMAfloN Drv.orlTl$RlJtffit*
Tank owno, ""-.r r." r"rr,, .e Phone # ( 801 ) 625'2696 -
t I dba (individual doing business as) [ I sole proprietorship [ ] partnership I XI corporation
Address 3939 Harrison Boulevard citv ooden State-UlaL zip 84409 '
Tank #
Age of tank
s'f$sL
1 986
Caoadty-.]$QQ-
Subs. stored'-P!959!-
Date last used -941!!-
. tndicate the specific substance stored in each tank to be ctosed (regular' unleaded' diesel' waste oil' etc'l
For waste oil tanks: Have degreasing or other types of sotvents been stored or mixed with the waste oil?
Yes (identifY if known)No
-
Not known
-r.,1#$iory -
Fac,w Namc McKav Dee Hosoitat Address 3g3g Harrison Boutevard ciwlgdg!- state-lraL ap 84409
Contad person John Grima Phone # ( 8Ol I 625-2696 -
Total number of regulated underground tanks at this site Two
Total number of regulated underground tanks at this site to be ctosed One -
TANKS TO BE CLOSED
Analysis for lead may be required prior to disposat of contaminated soil or other material'
TANK REMOVER Name Jau. .-. Mark ."r,1-fngr-pjt- Exp. date-UJ!!9!-
Phone#(8Ol )975-9091CompanyTarfra Tach- lne-
Address 1555 west 22oo south citv salt Lake state-UlaL zip-E4l-!-g -
SOIUGROUNDWATER SAMPLER Name Jack F. Mark Cert. # GSO361 Exp. date--!-€!!€5--
company Tetra Tech. lnc. Phone # ( 801 I 975-9091 -
Address 1555 West 2200 South S Citv@ state-!g]l- zipS!719 -
Before t'rc closure plan is submitted for approval, the toca! health and fire departments whare the facility is located must
bc contacted.
CONTACT LOCAL HEALTH DISTRICT Name of Dist. Weber - Moroan District Date3l2glg{
Contact Joseoh Decaria. Title Environmental Health Soecialist Phone # ( 801 I 399-8381 -
_CoNTACT LOCAL FIRE DEPT. Name of Dept. ooden ciw Fire Deoartment Date 2128194 '
-Contact Bob Wrioht Title Fire Marsha! Phone # ( 801 I 629-8070
DTSPOSAL TNFORMATION
Tank(sl will be disposed at: Facility lntermountain steel
Address 291! pacific Avenue citv ogCe!- State-UlaL Zip-9!&1-'
contact porson carrol straohn Phone # ( 801 I 621-4563 -
Product tines wilt either be:
-x-
removed ot
-
deaned, secured in place' and capped'
vent lincs witt either be:
-x-
removed of
-_deaned
and secured open'
Piping will be disposed at: Facitity lntermountain Steel -
Address 2911 pacific Avenue Citv--9gdeo- State-IrEh- Zip 84401 -
Contact person Carrol Straohn Phone # ( 801 ) 621-4563 -
Tank(s) will be cmptiod by: company Advanced Petroleum Recvclino Phone # ( 801 ) 364-9444 -
Tank(sl wilt be clcaned by: company Advanced Petroleum Recvclino Phone # ( 801 ) 364-9444
contaminated watcr gonerated by cleaning will be disposed at: facility Advanced Petroleum Recvclino -
Contact Person Brad Oaklev Phone #( 801 l 364-9444
Tank(sl will be: purged or
-X-
rendered inert by the following method: Drv lce
Residual studges will be disposed at the following facility: E.T. Technolooies -
Address 603o west 13Oo South Citv Salt Lake State-UleI-- Ap_8a11.6 -
contact person Ted sonnenburo Phone # ( 801 I 973-2065
For Closurc in-olaca:
t I Facility Site plat, Sample lnformation Table, sample results and Chain of Custody forms are included.
t I Approval for in-place ctosure has been granted by the Local Fire Department'
Fire Dept Phone#- Contact Date
t I Approval for in-place ctosure has been granted by the Local Health Department'
Health District- Phone#- contact- Date-
I I Substance to be used to filltanks
Tld FOLLOWNG MATERIALS MUr\ BE DTSPOSED AT AN ACCEPTAB1E F',<lUTY:
All matcrial3 glncratcd from UST closures must ba managed and disposad in a mannsr that does not place those
matcrials in dircst contact with thc environment. On-sitc stockpiling of conbminated soils may bc required prior to
any soil managcmont activities. tf aeration of contaminated soil is proposed, prior approval will be required by the
Exacutiva Secratary as part of the Correctivs Action Ptan requiremenb. Before ttre closurs plan is submitted, $e DERR
LUST Saction must bc contactsd at (8011 5364100 for aeration and permitting requirements. l, aeration is not planned,
indicats thc soil disposal facility below.
I I Contaminated Soils wil! be aerated.
DERR LUST Section contact for aeration: Name,Date
Contaminated soils are to be disposed at the following facility:E. T. Technolooies
Address 6O3O West 13OO South City salt Lake state-llg!- ap-g!lJS-'
contact person Ted sonnenburo Phone # ( 801 ) 973-2065 -
Contaminated water is to be disposed at the foltowing facility: Advanced Petroteum Recvclino '
Address 529 West 400 North city-&!!-tak9- state-uEL zip-8re'
contact person Brad oaklev Phone # l8o1 | 364'9444 '
SITE ASSESSMENT
A sitc assessment must ba performed for alt UST closures and change'in'service. Site assessments must bc performed
as ouu:nea in R31 1-2O2, pa:t2gO.72and R31 1-2O5 (U.A.C.l. !f contaminatiot! i$-susoecied. additional samDles must
ie collected at thc tocation where contamination i. most likelv to be oresent. Soil and Groundwater samples must be
table' using the appropriata lab methods'
complete tre Facility sitc plat and sample lnformation Tabtc on pages 4 and 5 to provide site assessment information'
CONTAMTNATION INFORMATION
lf contamination at the facility is susoec-ted or cgfigllgd, the information must be reported to the Executive secretary
(UST) at (go1) s36-4too *itrrin zc rroris. TIZ oiri"ion of water oualitv must be notified at (8011 538-6146 if
contaminated groundwator or surface water is found. lf contamination is confirmed, a oualified environmental
consultant should assist in the remediation process.
iiiEl"*nt that contamination is found, the environmental consultant will be:
Company
Address 1555 West 2200 South Suite '8. city salt Lake State-Ulab- z]p3!1J-9 '
Contact person Dennis R. Ridino Phone # ( 8O1 ) 975-9091
CONTAT{INAI{T COMFOI'NDS TO BE ANALYZED
t0l5 Modifid !!4
EPA 6U2 q 624Toul Parolcum Hydrocerboar (fPtI)
Brlr:cr,. Tolucm, Ehylbcnzce' Xylerrr (E[EO
E0l5 modificd gd
EPA 602 or 624
t0l5 Modilicd sl
EPA t@OTorrl Fclrolcum Hydrocr6onr (I"lD
kor*,Tolucr, Ehylbcrcc, Xylencr, Nephthrlcnc GiIE(}{)
EPA4t3.l or4lt.l
and EPA 6O2 ot 624
!!4 EPA 601
EPA 413.1 or4lt.l
sE EPA t@0!4
EPA tOIOHdogcortcd Organic Coryouodr
Oil ud Grcrrc (O&G) or Totrl Rccovcrablc Hydrocrrboo (IR[I)
bsr*.Tolucnc, Ethylbcnzcnc, Xylcncr, Naphthalcnc GiIE(N)
EPA 413.1 or4lt.lEPA 413.1 or 4lE.lOil ud Grerrc (O&G) or Totrl Rccovcrablc Hydrocartou (I?IQ
t0l5 modilicd !!g
EPA 413.1 or4lt.t
!d
EPA624
t0l5 Modificd 4!
EPA 413.1 or 4lt.l
Ug EPA E240 or
t260
Totrl Pctrolcum Hydrocerboar (fPE)
Oil rad Grcrrc (O&G) or Totrl R'ccovcrablc Hydrocrrboru (I?If)
Volrrilc Orgenic Conporodr (VOC'r)
Or othor EPA nrthodr ar lpprovcd by thc Exccutivc Sccrctrry
FACIUTY SITE PIAT
Thc sitc plat nrurt chow locations -r alt bulldlngs, str4ti, proprrty bound6t.--, tankt, piping, dlspcnser islands, and
undcoround utllitcr. The site plat must be drawn to an approitia'b ident'fiT! scale. !t must show proposed sampling
tocations, substances storsd in tanks, "nJ o$r. r"levant information. Tank and sample identification mu$ be
consistent with the information given bn p. 1 and 5 of the closure plan'
= Sample locations (SS'#, WS'#, USC-#I
= Monitoring Wells (MW-#,l
= Soil boring (B-#l
= Wator Wells (domestic, livestock, etc'l
x
o
o
o
4
Date 2128194-
ss-tl Y Undrrground- StoroooIank -
Porking Areo
SAMPLE INFORMATION TABLE
Gomplete table for all samples to be --ren for closure.
Sample # Sub. stored Spl. typer Depthz Compounds3 Analysis method(sll
in tank
SS'1 Diesel Soil 9 feet TPH. BTEX 8015 Modified, EPA 8020
SS-2 Diesel Soit 9 feet TPH. BTEX 8015 Modified. EPA 8020
SS-3 Diesel Soil 3 feet TPH. BTEX 8015 Modified. EPA 8020
' Soil (SS), Groundwater (GW), or Unified Soil Ctassification (USC). a s c s' *4 tl 'ty'ty' , ,.r.2 Approx. depth in feet below grade. All samples are to be taken atO-2 feet betow the backfil!/native soil interiace.3 Contaminant compounds to be analyzed for each sample (from tabte on p. 3).a Appropriate analysis methods for contaminant compound(s) in each sampte (from table on p. 3),
Approximatedepthtogroundwaterinthevicinityofthetanks:@Feet.
Regiona! groundwater flow direction: East to West
State Certified Laboratory to be used: ENVIROPRO Laboratories
Address 1600 West 2200 South Suite #104 City Salt Lake State Utah Zip 84119
Contact person Rudv Labban Phone#(8Ol )974-3114
Please explain any unusual or extenuating circumstances expected regarding the site assessment or closure:
I certify under penalty of law that ! am the owner/operator of the tank(sl referenced above and that I am familiar with
the anformation on this form and that
will be followed during tank closure
Signature of tank ownel
Full Name of tank ownel Date d -48-7(
tOeOOoLb
l..rdT I nstallation/Upgrade Notification
The Utah Underground Storage Tank (UST) rules (Utah Administrative Code R311-203-3) require that UST lnstallers notity
the Executive Secretary, Utah Solid and Hazardous Waste Control Board, 30 days before installing or upgrading any
regulated UST system. This form has been prepared to assist you in providing this information. Before installing or
upgrading an UST system, please complete this form and retum it to the Division of Environmental Response and
Remediation at the address below. lf any tanks or lines are removed or replaced, a Closure Plan for those tanks or lines
must be submitted and approved, and a site assessment must be performed at closure.
Facility lD# (if not a new facility)
.ll
f XL New lnstallation zy)-apgradeDate work will commence Apri'l 'tR, 1 ea4
TankOwner McKay Dee Hosoital
Address 3939 Harrison Boulevard ciry Ogden State..L166_ zip J4499_
Contact Person in charge of tanks John Grima
Phone#(801 | 625-2696
Facility Name McKay Dee Hospi tal
Address 3939 Harfison Bou'levard City Ogden State tLtah ZipBAAgg-.
Contact person__Jqhl !_r'!.tma Phone#[phone]q5
Certified Tank lnstaller Name Jack F. Mark Cert. # T10114 Exp. datefu!)11llL
Phone#(R01 ) qzc-qoqrCompany Tetre Ttrch^ In.
Address 1555 West 2200 South Suite "8"city Sal t Lake C'itv State-914[_ zipj4Llg_
lnstallatiodUpgrade lnf ormation
Tank #
lnstall/upgrade dV
Capacity (gallons)
Type (FRP, Steel, etc.)
Substance to be stored
550
Jac.kelc-d-Steel-
D i esel UTAH EEPA++Ffi{g+{+
ENVI HoNldl EryTAL CUALI Iy__Piping Type (Press., Suction, Gravity) Sur_tion_
Els.qtr-Uon.
El e-q!-_Uon._
Form of Corrosion Protection Polyethy'lene Jacket DIV. OF ENVIR,3i.JMEI.JTAL
R$Ft,retrnn o-ffi E-s rnl o N -
Tank Leak Detection method
Line leak detection method
Spill device to be installed (Y/N)
Overfill device to be installed (Y/N)
-++Af
lt-t5yf
Yes
Yes
Unusual or extenuating circumstances expected:,
Mail completed torm to:Utah Department of Environmental Quality
Division of Environmental Response and Remediation
168 North 1950 West, 1st Floor
Salt Lake City, Utah 84116
State Use Only: Date Rec'd 3- rS -t{ Rec'd By P{\* Notice Sent To O/O 3- tS -'iti iilr.r.,m luEr'gg
Michacl O. l.cavin
Govcfnq
Dianne R. Nielson. Ph.D.
Exccutivc Dircctc
Kent P. Gray
Dirccta
^\
\i-i-:"-'- :-- 'a
,r
DEP.TRIT\,IENT OF -ENVIROM{,IE}trAL QUALITY
DTVISION OF ENVIRONMENTAL RESPONSE AND REMEDIATION
150 North 1950 Wcst 2nd Floor
Salt Lakc City, Utah t4l 16
(80r) 53641m
(t0l) 359-8853 Fax
(tol) 536-4414 T.D.D.
FACTLTTY r.D. #_t2oct?.g 0
Dat,e:
From:
Enclosed i, ,t. information you requested regard.ing:
L Tank Notifrcation Form
Tank Closure Plan
Tank Closure Notice
Certified Tank Installers & Removers
State Certified Labs
Certified Tank Testers
Utah UST Administrative Rules
Utah UST Act
EPA UST Regulations 40 CFR 280
Billing Information
Release/Leak Inforrration
MUSTS for USTs
Dollars and Sense
Leak Detection Informationi
Certified Groundwater & Soil Samplers
PST Fund Information
Other:
Message:
If you have any questions, please contact me at [phone]. f;rt"^ a ( ,^, , {+., P Sf ?o,c1+1)
,+
tuo,l, & r-s'
-lX*n""'*
Sincerely,
Pnnteo on recyoed oaper
n
Incidence
Y/N
Y/N
,t
{
FAcrLrrY rD ' P Oa o"O
PROCESSING CIIECKIJIST
Year q I
Unacceptable
Non-Marketer Discount
Previ-ous Pollution
LUST File
Form Included
Acceptable eppl?luur"
/
tu-t? qa
J
,r/TTT
- Verify tank/Iinesvs relistered y /N \-/
Documentation ok? y/N V
r Rate ok? y lN O/
Qth-*nd Paid
,-
,.r r FY st? 'r"r'sfkfihsl?tOVr""= paid y/N 6 r' l/a -'
w*,Y/
W Fy 88? _"/_7
FY 8e? WPct[ral"o
FY gO? /
Fy s..? $w{y/6u qirzf?r)
t-
I compliance
&6t- compriance outsrandins? @*
- Leak detection requlred & in use? y/N
- Notification up to date & complete? y/N
./A
/
@+L
Date Qualified
Review completed and certificate issued by
suPPoRT\CE \CHECKLI ST. PST
l5z
'+
PETROteUnn StOhAGE faur FUND
FACILITY INFORMATION:LOCATION OF TANKS:
T.HE Owner Name:
Street Address:
City:
Flu:trrv ur. #- I ZOoo i o
APPLICATION
State:
Pnone: _ b5= aaae_
Contact Person: :JD/tuz)E^ralrs
TYPE OF OWNER:
[ ] Mart<eter, or non-marketer with annual monthly throughput greater than 10,000 gallons.
,/ N Non-marketer with annual monthty throughputiess thin 10,db0 gallons tnault vefitvl.
DESCRIPTION OF UNDERGROUND STORAGE TANKS:
Tank #
hge
, /Capacity" Substance
R2 ves25obe
BIE9E OIL
TANK TIGHTNESS TEST
Tank #
y'asslFail
CERTI FICATE OF REGISTRATION
14 Al! Underground Storage Tanks (UST) at this facility have been registered.\./ | I All registration TANK Fees have been paid.
COMPLIANCE WITH UST REGUIATIONS:
PREVTOUS POLLUTTON INCTDENT(S)
Have you ever had a pollution incident at your facility? NO[ ] Yes -- lf "Yes" please provide LUST (Leaking Underground Storage Tank) lnformation:
>4 No - tf "No" please attach a letter stating that under customary business inventory\-" practice standards you are not aware of any release from any tank(s) at this facility.
PST FUND FEES
t ] Full payment for every tank at this facility is included with this application.I I Quarterly payment(s) for every tank at this facility are included with this application.
I certify under penalty of law that the above representations rnade by me are true and correct.
Applicant's signature:Datesigned: (a"4(- ?D
\z\r'
iP.ErHOIEU,lrt.',,SrO,Rfi cE,.tfnr...,rUN.D....CH,ECKtlSfl
1. CERTIFICATE OF REGISTRATION:
Underground Storage Tanks (USTs) have been regislered -.lorm. Z^ryg (Re$sed_9-89)..
listrati6n Tank FeeJhave beeh paici - 1988/1989 ; $2sltanUyr, 1990/1991 : $45ltanWr
2. COMPLIANCE WITH UST REGULATIONS:
@ce with release detection requirements.
I I Tanks lnstalled belore 1965 o] unknown: release detectlon by Dec. 1989.
[Nztanks lnstatted 196$1988: release detection to be completed by my compliance date.
I I Release detection completed upon installation.
6l ^ in compliance with all other Federal, State, and Local UST regulations.
3. PST FUND FEES - ANNUAL FACILTTY MONTHLY THROUGHPUT:
t I I arn a marketer, or I am a non-marketer with annualfacility monthly throughput greater
than 10,@0 gallons.
t I $zso payment/tank: Flscal year (July 1, 1990 - June 30, 1991).
I I Quarterly payments @ $62.50nank (Due the lst day of Jul, Oct, Jan, and Apr).
t6^a non-marketer with annualfacility monthly throughput legs-tlqn ]0.090 gallons.
ii(nave compteted the APPLIoATIoN FoR NON-MARKETERS DISCoUNT form.
I I $teS payment/tank Flrcal year (July 1, 1990 - June 30, 1991).
I I Quarterly paymenb @ $31.25^ank (Due the lst day ol Jul, Oci, Jan, and Apr).
4. TANK & LINE TIGHTNESS TEST - ACTIONS REQUIRED AFTER TEST:
I I AI! systems pass the tank and line tightness tests.
t i I am submitting the results of the taik tightness test and a copy of the field report.
I I Alltanks do not meetthe requirements seJ b.y rule regarding tank tightne-ss testing.
[ ] t nave contacted the State UST office and wil! submit evidence of a plan for review.
5. PREVIOUS POLLUTION INCIDENTS:
I Self lngurance [ ] Guarantee
t I Risk retentlon grouP I I Letter ol Credit
I I Commercial lnsurance I I Surety Bond
[ | Other:
tf truCtOeNTS form which states whether
LiOer customhry business inventory practice standards, I am aware of any release from the
tank.
6. INDEPE].IDENT FINANCIAL ASSURANCE (KEEP TECOTdS At
t I I have obtained ftnancia! responsibility requirements for the first $25,000/release:
I I I have obtained indeoendent third-party financial assurance by my compliance date.
t i t witt obtain independent third-party financial assurance by my compliance date.
*See explanatlorc under "Horv do I g€[ stanod?'
^
Tanl*: Autditor (tm)
Copyr ight Leak Detertion Systernsr 1?86, 1?87" L98E
Tanl': testing system ver'sion I.1?, released tl5/I.3/B?
test rLrn *3
crperatnr-'s cornments i /Tan[;, Heavy Traff ic . r/Date tr time :=TiB-/E17gr_rvc-r9: I1r?l
Company narne - IHE* IvlcF:.ay-Dee Hmspital
Tan[,: ID * Eenerator Diesel
Tan!,; Location * East of Boiler Fioom
Frcrdltrt in tanh: - *? DieseL\/
Curstamer- contact - John Dennis
Fhone nurmher (8O1) 627-?Bt)t)
Street/butilding address * I93? Harrison B1vd,
Iity, stater riF, trtc - Ogden, Utah 8440?
Et-rstomer F.O # - N/A -/Tanlr capacity (ga1lons) ?.3t:t$*y'
Tank diameter' { i nches} t?*vz
Fi 11 diameter- ( inches) 4
Fi11 to tank top (inches) * tA'
Observed API 43" I*
Observed temperatutre (F) gQ"Ct{-tu./
Eorrected AFI - :O33. OO
Coef of expansinn (F) or O - O' OOfl4943
Are tanl:s inter-connected * n -
All valves closed - y -Is vent restricted n
Stee1 or fiberglaEE tank
Approximate age 72 -
Vapor recovery systern * n
l,rlater table ( if i::fir:Wn) - 1ow
I nc hes of water- i n tank 1 "
Sutct ion, Turrbi ne or No putmp
trleather and temper-atutre Sutnny Hot
Test condr-rcted try * Fatr ich: El L:iworth #Cxl5?
Test witnessed by - None
Cornments
Tr,rt, Ftrru L tr
produrct eLevation in tanll (in inches) - 1f,4'Ot)
ter:it r-Lrn on t-tb/2I /9tt at 14: (-,8x {-}3"
The level data for this analysis starts at 14;.15t 45 and ends at 15! t:,7! 21.
The ternper-aturre data fnr this analysis starts at 14:41:45 and ends at 15tO7;?1,
The vnltage rhange fmr- a calih,ration volutme of 2* rnl- was 0"O41 volts
Di rect readi ngs tal':en at the endpoi nts of the selectetJ analvsis per iod
shnw an auditnr probe change of t"t.179 mV in .11 rninuttes and .16 secnrrds
't his is a grc:ss ievel change af EB mL i n .51 mi nurtes ancl .1,5 seconcls
'T'atlinrl a1.1. tlre :intermr*cJ:i.atr.,: cla.t.: inLo r:o,-rtiidsrat:i.t:n L:y perfrtrrni.nq; &
Le.'lr;iit *i:.lL.rfir'{..T t"t:qr-erir";:i,;:i"i ui: lr*v*1 nn ti.m* git,e* *i.n ;.i,r..ir-Ji.'L:ilI" !-.irqhe sloptt+
-- /L.-...-
i..,f r r..ir...i1,: vuIl-3.ritrjL-iI =
l-nt..ti,+.,- t:.iii: ,tl f"fiF:rEi nrEiiLi':t rnitnir:r i.i* inrre;i::intl r,r;A !L.--.---.t tc! r--./ itt-rl.il' r
l.-!::i:Lrii::i i.: lrr: ral.cLrie,te':i i:E:rntreratlrre Eiilpe o+: {)"(:i(:}i::,57 dr:cjree's il
.r.rii:J 'iirr.* i:-i:rri:+ff.i.u:i.nrrL: il# eun.*i-r:s:i{::ir-i,, Lht* effect ni:: 'l:xmr:r.:ratL-tr't*
clr-i :i. nr re.tEie i. i"t vfi i. i-iffiiii nf 1. I li., : mL-./ hr
li:it!:: L. r;:rc:: t :i i-irl t ltq'i l-,:t ti::t-itulcl lemperatutre
F r'ficir..ri: 1.. 'ic:.1. r-rms: r:: harrqe V j. e I d L.lrH
i_r'r'i3:; rni*. z'htf L{ r .
. -_ 1 _ . _- -v L-r _L L.il il t:,..- L. ... -.. .... -.. t_.- - - r ,- -I rr.-{tittrJ ?_rtlill LI|b.l
.-].r---.-! .-.1c: clr t- *rc 1: 13(:i vr: t. Lirn#]
../ hmu r'
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i\. ++;:;:i? rritelr-ia ('{-.i-' (.}"
!\l " i- ,, f' " |{, 'F.-:,.'i.? i.. I I r...*I I ci
!-.LJ LJI I lr'
,' ,'F''i rrinn 1e+i+i.': :int:jj.r:u.ta*Cl
,i ,j -[ar"t!,: .l e':l': i rl# i i:.:.r'[t*tJ
i'..*.i -! r';l$'L i. r-tcnnc 1t-ts.iv*:;
i..._,/ fi:ir nt- Va.[:rnr' f.r'"ril :i.n':l:i.tai:.t'lcj
! -..-i 'i-
u+ ni;:: *: r' a f lr r *ir :i. ir x t- a Lr j. L :L i: .,u
! .-_l i rn$ r *1.:,:+ r- j. ni*'i: a .i. .i. a i: i r::'i
1:rr**t- {:t:n,llrc: '[ecl by F.*.'tr-:i.i:!,: E.i. 1r*r.tr:r'tf-r #i-,i]s?:i $itInfrtLli-H
t:** L L+ j. tn*iiitlsrlr:l i:..y l\l*rtr.* i s:i t,lrra{::t..lf"tiri
i"l .... .... ,-. -- .-. .i- * ..t...t._rilil!ti* : i r-. :".. ;
INDUSTRIAL HEALTH INCORPORATED
O4O EAST WILMINGTON AVENUE. SALT LAKE CITY, UTAH 84106
' (801], 466-2223
VOLUMETRIC / PRESSURE LINE TEST
Phone: 4t- lL- - 7&tOCLIENT:
Address:
N, -'J{^ 6r*r'}-.
Number of Dispensers:
Was "Tank Auditor'' Utilized to Confirm Status of Check Valve?
Line ldentification:
Angle Check Valve:
Pump Make: Submercible/Suction:
Time1. z\*
2. 3 r ll3. <.u
-
6._7._8._
R ES U LTS:
TotalChange (inches)(
= Rate (ml/hr) (
Allowable = 95 ml/hour
38 mUhour
Comments
Extractable Check Valve:
d
<r-a
(-1
Pressure
4<
v-(
Y-<+(
) X 206.5 ml/ in + Time (min)( ) X 60 min/hr
)
i(.OeS gats.) - Suction(.01 gals.) - Discharge
ht:- Untestable:-
,^,"'i l,r lr"
6a
Tester, Cert. No.
&k^ L"^'utnLJ"jl- (* J*''/ po.f. o( G+ wl*)
Line Test lnformation
6-15-90
Pressure of Line Test: YS P t,
ChangeoLevelik
4)
s/a
INDUSTRIAL HEALTH INCORPORATED
,ilo EAST WILM]NGTON AVENUE
SALT LAKE CITY, UTAH 84106' (go1l 466-222s
VOLUMETRIC / PRESSUBE LINE TEST
CLIENT:
Address: Wl
Une ldentification:
Angle Check Valve:
Gr.tD
Phone: &>t - (77- ZAqo
Ur
L,^.^4 L,aL-(.{"
Extractable Check Valve :
Pump Make: Submersib'@'
Number of Dispensers:Pressure of Line Test:
Was "Tank Auditof' Utilized to Confirm Status of Check Valve?
Time Level Change
2._3._4._5._6._7._
8..
R ES U LTS:
TotalChange (inches)(
= Rate (mt/hr) (
) x 206.5mt/in +
)
Pressure
Time (min)( ) X 60 min/hr
Allowable = 95 ml/hour i(.0e5 gals.) - Suction
38 mUhour (.01 gats.) - Discharge
Dare: t f rt
Comments
No +rl
,/
Untestable: K
lqo
k+=- M, G+ vil,,o on {LAr. l,n-L.r LrJ P,,])
Line Test lnlormalion
6-15-90
rt. No.
INDUSTRIAL HEALTH INCORPORATED
,A4O EAST WILMINGTON AVENUE
SALT LAKE CITY, UTAH 84106' (aa1) 466-2223
VOLUMETRIC / PRESSUBE LINE TEST,BE LINE TEST
'M phone: bt - (ra-l- ?-BCLIENT:
Address:n
Extractable Check Valve :
2._3._4._5._6._7._8._
R ES U LTS:
TotalChange (inches)(
= Rate (ml/hr) ( )
Atlowabte = 95 ml/hour j(.OzS gats.) - Suction
38 mUhour (.01 gals.) - Discharge
Line Test lnformation
6-15-90
Pressure
) X 206.5 ml/ in + Time (min)( ) X 60 min/hr
Line ldentification
Angle Check Valve:
Pump Make: submersibre@'
Number of Dispensers:Pressure of Line Test:
Was "Tank Auditor" Utilized to Confirm Status of Check Valve?
Time Level Change
./
Untestable: V
-
a\q
Tester, Cert. No.
Date: cftlqo , .7 t
comffiis ,t-rt f".k - No G"+ volu. o( 6r'/- P,, k or' U",,;*_
INDUSTRIAL HEALTH INCORPORATED
.640 EAST WILMINGTON AVENUE' SALT I.AKE CITY, UTAH 84106
[phone]
LINE TEST
Phone:CLIENT:
Address:
Une ldentification l, l,*5"
Angle Check Valve:Extractable Check Valve :
Pump Make: Submersibl
Number of Dispensers:Pressure of Line Test:
Was "Tank Audito/' Utilized to Confirm Status of Check Valve?
Time Level Change
6
78._
R ES U LTS:
TotalChange (inches)() X 206.smt/in +
Pressure
Time (min)( ) x 60 min/hr
= Rate (ml/hr) ( )
Altowabte = 95 mUhour l(.025 gats.) - Suction
38 mUhour (.01 gals.) - Discharge
Tight;
signature
oa.,rltafrc
Comments t
N" l.q{ Po.k - ,Mo tr+
Untestable, X
,)"1. or J"-r/ f-r+ o fu.L,n l,^-
Line Test lnformation
6-15-90
Tester, Cert. No.
F,SUTY tD. * l?O,.oqO /
.:iffii1.-t-*",1f$fiiisr;[iffii::ffi n
To: Mr. Dennis Downs
Executive Secretary
Utah Solid & Hazardous Wastes Committee
Dear Mr. Downs:
As required by paragraph 26-74e-4O4 of the Underground Storage Tank Act, I have
performed a tank and line tightness test on each underground storage tank at my facility,
and based on this test, there has not been a release of petroleum. Additionally, based
on "customary business inventory practices standards", I am not aware of any release of
petroleum from my tanks.
PREVIOUS POLLUTION INCIDENTS
o&
I have had the following releases of petroleum (detailed below; also mention any action
you took to clean up the release).
signature of owner/operator
Failure to report previous releases could void your coverage under the Petroleum Storage
Tank Fund.
signaturE of owner/operator
v
State of Utm
DEPAHIMENT OF HEALTH
DMSION OF EIWTRONMENTAL HEALTH
Eureau ol Solid & Hazardos Wasle
288 North 1460 WesL P.O. Box 16690
San Lake City, Utah 841 t6{690
v
u.8. FU'TAOEPAID
St lJGCry, Ut
PEMtrT 15. TI}I
MCKAY-DEE HOSPITAL CENTER
3g3g HARRISON BLVD
oGDEN, uT 84409
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Consu/tants in Occupational Salety and Health
July 17, 1990
Bruce Clark
Director, Support Services
lntermountain Health Care, !nc.
1 180 West 2600 South
Woods Cross, Utah 84087
ffiHffiffi.qvffiil
AUc *li 1990
u**,Ylti*onll[
,:l#ffiji
" " "'
RE: Results of Tank Tightness Testing At the McKay-Dee Hospital
Dear Bruce,
Enclosed are the results of the tank tightness testing and a site map showing
the location of the UST at the McKay-Dee Hospital. The tank tested tight. This
tank had four product supply lines connected to it, however, only one of these
lines was testable.
The supply line to the ngrt[gp1ga'lor tested !ig[t, however, the return line for
this generator was not testable. None of lhe other three lines were testable.
Also enclosed is the necessary paperwok for accessing the Utah Petroleum
Storage Tank Fund.
lf you have any questions, please feel free to contact me.
Kent Wheeler
Senior Hydrogeologist
encl: Tank Test Results
Line Test Results
Site Map
Tank Fund Paperwork
lndustrial Health lncorporated 640 East Wilmington Avenue Salt Lake Crty, Utah 84106
Sincerely,
Telephon e: (8O 1) 466 -2223 FAX: [phone]
INITIAL iNSPECIIt]N & COIIPLIAI{CE SU!.IiIARY FORH
ID No. I -c;cf'l) coraoiiance # / SussenseInsoector (n)-oate 4-tl-1r:
fank ownqr
-Ind.
dba :.Cp.p_. other oate(acguired/Inc. )_*fU/^**,
STNEET
CITY
Closed Out
coilTAcr IITLE PHOTIE
fanr Ooerator [nc-dba Corp.Othcr Otte(acgui redllne. )_
BUSII{ESS NAHE_FACILITY NO.
STNEET
CI
c0rTAcr IITLE PHOTIE
VTOLAII()II/
COTIPLIAI{CE
RuLE__it 2-t,ATE
Susgens:
'l'--t t
Pcmlty
,
t
0ate
?CrsT coflTAcr
zllD CoilTACT
3R0 C0ilTACT
4TH COTTACT
[w
ONOER
FILE.A6
EPA REFERRAL
.:fl neF nllt
0ate Action
I te ,-' g,
Other oate ( acgu i reo/ I nc .IInd. 'Jba :r'D.,oogrti.'' :
Al{E_
TREET-
:TY-
-Arr #
.TATUS
..rL
:HTER}IAL
.XTER}IAL
PIPTN6
SUBSTANCE
LAST USED
CLOSURE
CERTIFICATION
?ELEASE OET.
OATE OUE
- -. . .-..r-F?a I
SP t LL/ UY I,TT, T LL
RELEASE DATE
iTE ZIP ACOU: RED
<a'-
----
---
In C,;mllanca?
# (Y/Il]
- -
-
--
- -
-
--
-
- -
-
-
- -
- -
- -
-
G
-
- -
Rule #(s)
:IISURER Pollcy #
Flnancial Resoons'ibl I ltv
HETH00
C(lt{tlETITS:
Esllt{-7767U-25-26
".F-
@
\orman H. BangerGr
Cffiot
suzanne Dandoy. M.D.. i{.Pti. Bureeu ot sohd & Haratoous waste
ExRumDlrF@r AggNonh t460West.pO gox 16690
Kenneih L.{.lkem. satt Lake crty. utah 841 l6-0690
Drrdor (801 ) 538-6170
BSHW-7 767U-26
t\TO: Li ,r !/t'ily\r-
RTMENT OF HEALTH
ON OF ENVIRONMENTAL HEALTH
Enclosed is the information you
,/\- Tank Notification Form
l'l'1 , [, ,\, ' |> u li,<,,f,'L, ( t
'tl-rtl .-i'i1v'r..a /r .[.il /
',lr .,I '.!./t 1( ( ,
OATE:7 - /t-?t'
i/_ ,:,/From: ,,' / lt7. ,-1 //,//l"r-,t
-t
Utah Oepartment,of Health
Bureau of Solid and Hazardous Waste
288 North 1460 talest
P.0. Box .l6690
Salt Lake City, Utah 84116-0590
requested regarding:
Utah UST Administrative Rules
Utah UST Act
EPA UST Regulations 40 CFR 280
Billing Information
Release/Leak Information
I.{USTS For USTs
}!*nr closure Plan
Certified Tank Handlers
Certified Tank Inspectors
_ Certified fank Testers
VCertified Groundwater & Soil //'\
5amp I ers
Other:
l,lessage:'1'(. ' k. ",1, t
If you have any questions, please contact me at 801-538-6170.//
sincerel v, ,,.. i / f:r- i2f,:*'--L't '/
t, 7-Lt"t''{ \
^,1\,'/fu -
-* i,. . ;"^,
't
\ .r'-'
TIME
-P.M.-J?co
4*.sbr* Q.,n
SIGNED
LTTHO IN US.A"
uZ)nti' f:.'-r*,
"/
e<'+''1
sb **o) *< *-
tf,ff t.ffi"15
roes Q FoHM soozP
a,
a\/.\lz@o7o
RECEIVED
Dear $ir
In rEEiponEE ta your letter dated Janutary ?{t, 1989 and received inrny n{#ice Febrltary ?7! 1989, I arn sending yc}Ll a capy of a I'temctaddre$Eiecl tf] )r'clLrr department hy t'lr" Hohert Reading in AutgLrst1988.
Brent C Bradfard
Futrealr s{ $t:1id and Ha=ardous Naste
?88 N. 146r] W.
F, O, Box 16&9(t
SaL t La[':e Ci ty, Utah 441 16*O6?(t
According to l"lr. RearJinqs ,rrefncr and yoLrr
e:rernBt frarn the f ass.
Flease re.,riew your records on this matterin {act ie the case.
I{ I can be o{ {urther. sssistance please
Attachrnent
$i ncera*I y
John Dennis
Director o# Hnvirsnrnental Services
Engi neering Depar-tment
S93? Harrig;an ELvd.
Ogden n Utah 944{)?
cc! Dave Call
MAR 21989
Utah DePt. of Health
Bureau of Solid & Hazardous Waste
to fiirn,bJE Sre
and let ,ne knt:w if this
contact rne at 6:5*2+33
t'\rMU
C \o .vy
,,IdY .ordlv\^- VfnV
Do"'
a\
HEHORANDUI'1
Plcl'iaiy*.Dee, Hosp i taI
Engi neeri. ng D*rpartrnent
3939 Harri sclrr S1 vd.
Egden, Ut " 844{}?
401-6I5*:0??
'f0: UTAH DEFARTI'IENT EF HEAI_TH
BUREAU OF SUI-ID AND HAZARDOLJS t,tAEiTE (UST)
P. O. BOX 166911
SAL'f LAI:E C I T'Y , UTAH 841 t 6
FROI{: fIUBERT READING
DIRECTIIR 0f: EN6INE:ERING
OATE: ilLJtitJST'8, L'?8fi
SUBJEUTT UNDEESftOUND STORAGE TANI{
trJe recent L y r-srcei';ed yclLrr memo and i nvoi ce {+SIt3 l denti f yi ng t-he
a$t;eI3$E'd annltal {ee ;rgainst or,+ners, C]f underqroltncl st(}rage tan[::s.
trle notice in yclt.tr'rnerno yBLr irrdicate cerrtain tanl':s are exempt frornthta {ee$" Ttre "UST" N€! havsr r:n r;ite containsi Dies;ell mil u lrged a$
;1 :3t,andby fltel {or- rsLtr boilsrrs in case of c1n in'l-errrltption in thstNatutral Gas $,ervicrr. We {eel we qr-raL if y f or ari e*xception nnd*rItem S? whi.ch statms; " lanl,.:s3 t.rti;eici f t:r' utr:ring heating oi I .f ar'
cons;urmptive r-rge un the prerrises wtrere s,tored".
I'f tl'lore {tre &ny quteis'L.ion fir- i't we can bs} clf arny }rel1p pLu+ase c,r1 1Rc:bert Fleading 6:5*:{tI?
Il"_8. _N.-..p- E".".ft..H . p__-tJ...I!
Plcl,.ay-Dee Hospi t;rl
Engi nee*ri ng Departrnent
$9f,9 Harr i scin Bl vrj.
Ogden " ljt. U44t)?
801*6?5--2{)I?
"l-Or LJTAI-I DEPARTI{ENT Of: l-lEAt-Tl.{
BUREAU OF SUL.ID AND FIAZARDOUS WASTE (TJS'I}
F. n" EOX I669r]
SAI..-T LA}.IH [: I TY " UTAH 841 16
f:R0t"t; FiOHEftT READINB-{'L
DIftTC}Oft OF ENGINEERINTi
DAT'E: ALIGUST 8, 1?gB
SitJBJEtlTr U]'|DHRGFiOI"iND STCIRAEE TAN],i
ble recr*nt 1 y recei'/ed ycllu' merno and i nvmi sn #5IlI3 i dent i f yi ng thei
agse$st*d annural {e,ss aqairrs,t t::wn$rs o+ utnderqroltnd storage tan}ls"
[,,1e notice in yoLrr rnerncr yc:Lr indicate cegrtain tanks are e]iempt'fram
the .f e€p5. lhe "LIST" we lravs on site cmnt;rins Dis*sel uil r utsecJ as
a stanclby fuel fi:r clt-rr- Lrcilt;rs in case of an irrterrutption in the
Naturr*1 Gas se*rvi ce, lrJel {eeI Fi* qr..ra} i {y f r":r' ;*fi el:lcepti c:n Ltrld(*r-
Itnrn *iI which gtates; "Tanh:s r.rserJ {trr storing lre*ting r:iI for-
cnnsutrnptives t-tsis on ttre pre*rniseg tltrers ritGrecl".
If ther-e are;rny question clr- if we can be of any help pleare call
F{obert Readirrq 6}5*ttlIt
RECHIVED
AUG 1 11988
Utah DeP1.6f l-ft*aith
Eur*au r:f $tl,.i i. fja.;:(uui itaste
n
r.1 F"*H g"-ts_4 N -P U t"r
DUANE HBRTENSEN
DEFARTI'IENT OF HEALTH
DIVISION CIF ENVIRCINI{ENTAL HEALTHF.B. BCIX 166?0
SALT LAl.lE CITY, UTAH
SEPTEIIEER 2 o t?87
{
!' -,1,u
T0r
DATEI
I
Plcl{ay-Dee Hoepital
EnginGrering Department
3939 Harrisen Blvd.
Ogden, Ut. 84409
aol-6?5-?fi22.
84116
FREIFT:- - --- RoBERT *=oo**-S--
DIREtrTCIR OF ENffNEERING
SUBJECT: UNDERGRCIUND STORAGE TANI{
hle recentl,y received your memo and invoice #1374 identi{ying the
aseesged annual fee against ownerg o{ underground storage tanks,
We notice in your rnerno yoLr indicate certain tanks are exempt {rem
the fees. The 'rUSTrr we have on site contains Diesel oilo uged as
a standhy {uel {or oLlr boi}ere in case o{ an interruption in the
NaturaL Gas service, We feel we quali{y {or an exception under
Item *? which Etatee "Tanks used {or storing heating oil {or
consumptive use on the premises where stclred".
I+ thene are any question t:r if we can he o{ any help please call
Robert Reading 6?5*?022