DERR-2024-004949

Tanks Installed. Use additional pages as needed.Tank No.Tank No.Tank No.Tank No.
New Installation or Upgrade
UL Number
Material of construction (FRP, Steel, Composite, etc.)
Double walled - dry or brine filled
Substance to be stored
Capacity
Date installed
Pre-installation pressure test date or vacuum date (dry interstice)
Reading of pressure or vacuum for pre-installation test (dry interstice)
Type of overfill prevention device (shutoff or alarm)
Overfill alarm has sign and is visible and audible to driver (RP100)
Type of spill prevention device (single or dw spill bucket, sump, etc)
Amount of tank deflection readings (initial)
Amount of tank deflection readings (hold down straps)
Amount of tank deflection readings (backfill top of tank)
Piping Information
Material of construction (Flex plastic, FRP, etc)
Type (Pressure, Suction, Safe Suction, Gravity)
Date pre-installation air test passed
Pressure for pre-installation air test
Installation Specifications
Do you have a copy of the tank manufacturer's installation manual and PEI RP100 with you Yes No NA
Certified tank installer Cert. #: TL Exp. Date:
Certified Installation Company Cert. #: IC
Visual inspection of tank(s) reveals it is free from damage Yes No NA
Visual inspection reveals no brine on either the inside or outside of the tank(s) (from interstitial space of brine tank) Yes No NA
Damaged components have been repaired by the manufacturer Yes No NA
Tank and piping excavations are free of debris Yes No NA
Depth of backfill bedding for tank(s) (must be at least one foot)
Type of backfill material (clean, free flowing, etc.) (Sieve report should match installation manual):
Geotextile fabric used along sides of excavation (recommended) Yes No NA
Geotextile fabric separates any secondary backfill (required) Yes No NA
Estimated depth to groundwater
Tank(s) are placed at sufficient depth for traffic requirements, groundwater conditions (check installation manual) Yes No NA
Tanks are outside the shadow of the 45 degree factor of a structure's footing (PEI RP100 Fig 4-2) Yes No NA
Distance from tank(s) to nearest property line:Distance from tank(s) to nearest structure:
Anchoring method is adequate for groundwater considerations. Note method here: Yes No NA
Hold-down straps are in place according to manufacturer's specifications (check installation manual if clamps are used) Yes No NA
Tank spacing is at least 18" between tank(s) and excavation wall (stable wall) or 18" between tank(s) and 1/2 times tank
diameter excavation wall (unstable wall) Yes No NA
Tank is level or sloped toward interstitial monitor probe Yes No NA
Backfill has been adequately compacted for full suport along tank length at 5 and 7 o'clock Yes No NA
Date of pressure test after backfill to top of tank (before piping is installed)
I (name) certify that I inspected the above-named facility on (date):
Inspector's Signature: Cert.#: TI
Ver. 10/5/2018
Page 1 of ___Utah Department of Environmental Quality 1000804
UST Installation Inspection
Ownership of Tanks Location of Tanks
MAVERIK, INC.MAVERIK #736
185 SOUTH STATE STREET, STE 800 85 W 800 N
SALT LAKE CITY UT 84057 OREM UT 84057
Page 2 of ___Utah Department of Environmental Quality 1000804
UST Facility Site Plat
NORTH
Show locations of all buildings, streets, tanks, piping, and dispenser islands. Indicate the product in each tank. Show locations of tank
manways and identify each: submersible pump (S), tank fill (F), ATG probe (A), interstitial probe (I), vapor recovery (V), capped plug (C), other
(specify).
Comments: