DERR-2025-000601

Utah DEQ Underground Storage Tank
Installation Notification Form
www.undergroundtanks.utah.gov
Facility ID New UST Install [ ] Upgrade/Repair [ ]
Installation Company:
Contact Name: Phone:
Address:
Tank Owner:
Address:
Contact Name: Phone#
Facility Name:
Facility Address:
Installation / Upgrade /Repair Information Est. Date work will commence:
Tank #
Capacity
Tank Material
Piping Material
Substance stored
Check if upgrade or repair only. (Describe details below)
Describe Details of Install/Upgrade/Repair in the box below (Submit a drawing/site map of work to be done)
Mail completed form to:
DEQ/DERR
Box 144840
Salt Lake City, Utah 84114-4840
195 N. 1950 W. 1st Floor
Salt Lake City, Utah
Phone [phone]
Fax [phone]
Ver. 8/1/2016
State Use Only
Permit Required?
Permit # _____________________
Base Fee $ __500
Inspection Fee* $200 x ___ $_ ___
PST Install Fee $200 x ___ $_ ___
Total $__ ___
Date Approved & Paid ___________
*Applies in non-LHD contract areas
Certified Installers/Technicians on project
Name Cert. # TL Exp. Date
Name Cert. # TL Exp. Date
Name Cert. # TL Exp. Date
Petroleum Installation Specialists
Thomas Dyckman
3075 Haun Dr. West Jordan, UT. 84088
801-673-3435
Thomas Dyckman
Smiths Food & Drug Centers
Smiths #153
2A
10k
1
20k
2B
8k
FRP FRP
Flex Flex Flex
FRP
unleaded diesel premium
295 4/2025
Mark Ellis
1550 S. Redwood Road Salt Lake City, UT. 84104
3/2025367Kelby Taylor
March 17, 2025
Installation of two UST's and all underground piping and 7 dispencers
10305 S. 1300 E. Sandy, UT. 84104
4002694
X
1632-2025-2
3 600
3 600
1,700
1/10/2025