DERR-2024-004944

Utah Notification for Aboveground Petroleum Storage Tanks
Division of Environmental Response and Remediation Phone # [phone]
Underground Storage Tank Section Fax# [phone]
P.O. Box 144840 Email: [e-mail]
Salt Lake City, Utah 84114-4840 Web site: deq.utah.gov
STATE USE ONLY
Facility ID#: 9000055
Date Received: 8-19-22
Data Entry Clerk Initials�
This form must be completed for each location containing aboveground petroleum storage tanks (APSTs) that are regula«\d
by the State of Utah.
I. Ownership of tank(s)
Owner Name Pilot Thomas Logistics
Mailing Address PO Box 2136
City Grapevine
Contact Bryan Christian
p h One # 304-204-1794
State TX Zip 76099
Cell# 304-550-1724
E-ma i I bryan.christian@pilotthomas,com
Ill. Type of Notification
II.Location of tank(s)
Facility ID # (unless new location) 9000055
Facility Name 140 Roosevelt-PTL
Street Address 380 South 200 East
County Duchesne City Roosevelt
Facility Phone# NIA Unmanned Site
Latitude: Longitude:
IV.Other
Zip 84066
IZl New Notification D Amended Notification □Federally regulated underground storage tanks are at
this location. If so, please enter the Facility ID assigned in □Located on land within an Indian reservation the space above under Section II.
or on other Indian trust lands.
Name of Tribe:
V.Type of Owner0 Commercial □Private□Federal Government□State Government□Local Government□Tribal Government
Name: Joey Huerta
□ □ □ □ 0 □
VI.Type of Facility VII.Exempt
Auto Dealership □Railroad □Commercial Airport(fueling)
Contractor □Residential □Farm/ Agriculture
Federal -Non-military □Trucking or Transport □Petroleum Distributor/Refiner (SIC
Federal -Military □Utilities Code 2911 or 5171)
Gas Station □Other (explain) □Oil or Gas Production and
Industrial GatheringR Heating Oil used on premises
Less than 501 gallons
VIII.Contact Person in Charge of Tanks
E-mail: Address: Phone Number (Include Area
[e-mail], 1051 Mustang Drive Code):
Job Title: Facility Manager Graoevine. TX 76051 432-638-8251
IX.Financial Responsibility
I plan to meet the financial responsibility requirements by using the following mechanism(s): /check all that apply)□Bond Rating Test □Local Government Financial Test U Surety Bond
Commercial Insurance □Risk Retention Group D Trust Fund □Guarantee □Self-insurance /Financial Test)□Other Method (explain)□Letter of Credit □State Fund /Petroleum Storage Tank Fund)
X.Certification (Read and sign after completing ALL SECTIONS of this notification form)
I certify under penalty of law that I have personally examined and am familiar with the information submitted in Sections I through
XI of this notification form and all attached documents, and that based on my inquiry of those individuals immediately responsible
for obtaining the information, believe that the submitted information is true, accurate, and complete .
Bryan Christian ��'� 08/01/2022
Name and official title of owner or owner's Date Signed
Authorized representative /Print)
Page 1 Version 10.12.2021 V1
Xl. Description of Aboveground Petroleum Storage f anks (comptete for eoch tonk at this tocotion)
Tank ldentification Number (use additionot pages
if more thon 5 APSTS)
Tank # 2 Tank # 3 Tank# 4 Tank# 5 Tank # 6
1. Tank system description (checkoltthot
opply)
(if either of these opply, the ApST is regulated)
Rests directly on soil (inctuding grovet)
Any portion of piping buried or touches
soil (inctudi ng grovel)
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2. Status of Tank (check only one)
Currently in Use
Temporarily Closed
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3. Date of lnstallation
4, Capacity (50lgoltonsandgreoter)15,000 15,000 15,000 20,000 4,000
5. Tank Attributes kheck att thot oppty)
Asphalt Coated or Bare Steel
Cathodica I ly Protected Steel
(impressed current)
Cathodically Protected Steel
(socrificial onodes)
Composite
(steel cldd with non-corrodible moteriol)
Concrete
Double Walled
Manifolded
Compa rtmentalized
Field - constructed
Steel Secondary Containment
Concrete Secondary Containment
Earthen Secondary Containment
Tank rests on cradles
UL LiStEd APST
Connected to an Emergency Generator
Other, Specify Here
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6. Overfill Protection (check oltthat appty)
Automatic 5hutoff
High-level Alarm
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7. Spill Prevention
Single Walled
Dry Connect Fitting
Other, Specifv Here
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Page 2 Version 10.12.2021V1
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13. Substance
Gasoline - Regular (up to 10% ethanot)
Gasoline - Midgrade (up to 10% ethanot)
Gasoline - Premium (up to 10% ethonol)
Gasoline - Ethanol Free
Gasoline Containing > 10% ethanol
(specify dmount of ethonol ond grode of product)
Diesel
Off Road Diesel
Biodiesel
Diesel Containing> 20% biodiesel
(specify amount of biodiesel)
Kerosene
Avgas
Jet Fuel
New Oil
Used Oil
Other, specify here
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14, Release Detection (check att thot opptv)Tank PiPe Tank Pipe Tank Pipe Tank Pipe Tank Pipe
Tank Tishtness Testine t-
Automatic Tank Gauging
I nterstitial Monitorins
Statistical I nventory Reconciliation
Automatic Line Leak Detectors
Line Tightness Testing
Comments
is facility is in the process of updating the infrastructure. New tanks, containment, piping, and
spenser are being upgraded for compliance purposes. An amendment will be made once
complete
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