DERR-2025-000417

PST Fund
Eligibility Application
9/18/23
Utah Department of Environmental Quality
Division of Environmental Response and
Remediation
Petroleum Storage Tank Fund
Were tanks in compliance when leak was detected?
Yes No
LUST Release Number: Facility ID Number:
Applicant Name (please print) Signature Date
Mailing Address
City State Zip Telephone
( )
Applicant is a:
Tank System Owner Facility Owner Tank System Operator Land Owner (Must demonstrate authority to file claim)
If the tank system owner or
operator, the facility owner,
or owner of the land on which
the tank system is located is
different than the applicant
shown above, complete the
appropriate spaces in this
portion of the form.
Tank System Owner Facility Owner Tank System Operator
Land Owner
Mailing Address
Telephone
Dates of Ownership
From To
Name of facility where the release occurred:
Facility Address:
Contact person at the facility: Telephone
( )
Date Release occurred or was discovered: Date release was reported to the DERR:

Number of tank systems that contributed to the release at the site (attach additional sheets if needed).

Tank Number

Tank Volume

Product

Installation/Closure Date

Is this release covered under independent insurance?

Yes (if yes, please submit a copy of your insurance policy) No

Number of tank systems that were or will be removed during the course of this site cleanup?

How was the release confirmed? (Attach a brief summary that includes laboratory analysis, field instrument readings, visual
observations, tank tightness test results, etc.)

Is there evidence of a previous release? If so, describe how the release was determined.

Was the release caused by a third party? If so, explain the circumstances and provide the name, address, and telephone number of
the third party and the third party’s insurance company.

Have you received any reimbursement or offers of reimbursement from a third party or a third party’s insurance company? If so,
how much and when was it received?

Have you signed a release? Utah Code Ann. 19-6-426(7) prohibits responsible parties from doing anything that may prejudice the
right of the State to recover from third parties.