DERR-2024-004917

PST Owner Information
Facility ID#
PST Facility Information
Owner Name: Facility Name:
Address: Address:
City: State: Zip: City: State: UT Zip:
Contact: Phone: Contact: Phone:

DESCRIPTION OF PETROLEUM STORAGE TANKS
Tank #
UST or AST
Date Installed
Capacity
Substance Stored

TANK/LINE TIGHTNESS TEST Indicate Pass or Fail for each tank and product line tested. Include a copy of the test.
Tank #
Tank Test
Line Test

TYPE OF FACILITY
Marketing facility, or non-marketer with facility average monthly throughput greater than 10,000 gallons.
Non-marketer with facility average monthly throughput less than 10,000 gallons.

COMPLIANCE WITH PST REGULATIONS
All Petroleum Storage Tanks (PSTs) at this facility have been registered.
Registration fees and Petroleum Storage Tank Fund Fees have been paid.

Are your PSTs currently in compliance with all Federal, State, and Local PST regulations, including applicable Fire Code?
Yes No If "No" describe items of non-compliance:

PREVIOUS POLLUTION INCIDENTS
Complete the Previous Pollution Incidents form to indicate whether a pollution incident has occurred at the facility.

FINANCIAL RESPONSIBILITY MECHANISM DECLARATION (check one only)

* Non-regulated PSTs at the facility may be required to participate in the Environmental Assurance Program.

I choose another Financial Responsibility mechanism for the PSTs at this facility.
• Indicate the financial responsibility mechanism to be used:
• (For self-insurance or guarantee) Indicate your company’s fiscal year end date:
• (For Insurance) Indicate the date the policy is renewed each year:
The Certificate of Compliance cannot be issued until all documents have been submitted and the mechanism has been approved. If
the mechanism has already been approved, submit documentation of coverage for the new tanks.

I certify under penalty of law that the above representations made by me are true and correct.

CofCapp 1022
Utah Petroleum Storage Tank Program
Application for Certificate of Compliance
I choose to participate in the Environmental Assurance Program (PST Fund) *.
• Indicate the financial responsibility mechanism to be used for cleanup costs not covered by the Fund.
• Indicate the number of non-regulated petroleum storage tanks at the facility.

Owner/operator Signature Date Signed

9000221
Wind River Petroleum Top Stop C-40
5097 S 900 E Suite 200 1355 E Hwy 40
SLC UT 84117 Vernal 84078
Jess Kuddes 208.220.6743 Dusti Burton 435.789.8292
1 2 3
AST AST AST
4
AST
5
AST
1950 1950 1950 1950 2002
17,000 10,000 12,000 12,000 9,600
Unleaded Diesel Diesel Supreme Diesel Off-Road
1 32 4 5
Pass Pass Pass Pass Pass
Private Insurance
February 1st
November 9, 2023