DERR-2025-000616

Page 1 of_Utah Department of Environmental euality
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UL Number
Material of construction (FRP, Steel, Composite, etc.) \ /
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walled - dry or brine fiiled d
Substance to be stored : r- - -<t -- i---'Substance to be stored .t
;+rh;: :: ,;,*t NP-llilstallation pres-sule test date or vacuum date (dry interstice)
4002691
,*r"""u"fi"n pressure test date or vacuum date (dry interstice) $
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Reading of pressure or vacuum for pre-installation test (dry interstice) n \ \ [
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Type of overfill prevention device (shutoff or atarm) \ I t \ a, ,Jv\/'nl
_Qvgmltalarm has si,gn and is visibte and audibte to driver (Rp100) , \1 ^f\\l
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Type of spill prevention device (single or dw spill bucket, sump, etc) \ \ \l \
Amountoftankdeflectionreadings(backfilltopoftank)M-o:ll gll"nk o9[t9cr!q1 rgadinsq (backfifl top of tank) '
Plping lnformation
tvp"ipi"i'ire,suction,.iiieSuction'Gravity)"ii"i}/.ai|,*
Date pre-installation air test passed
Pressure for pre-installation air test Sq nt 1
Installation Specification s f- "
::T"1:"":::::''1"1 Rvll &ecl-men cert#:rL iqz ,=*,n;t;; 6lzilie*
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 fooQ
Type of backfill material (clean, free flowing, etc.) (Sieve report should match installation manual):
Geotextile fabric used along sides of excavation (recommended)
Geotextile fabric separates any secondary backfill (required)
Estimated depth to groundwater
Certified lnstallation Com ' ft #. tc
Visual inspection reveals no brine on either the inside or outside of the t{nk($ (t qtinteistitirffi" oi Lii"I tinxl -'' '/
ves ruo @
,Ois]-q_1c9 fgm tank(s) to nearest property line: Di"trn"" t o, t"nf.trl to n".r"rt "tirA*",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 ls" between tanr(s; and excavation wall (stabte *"rrioi iii-oltirii"ii'ii"r,til il ,, ril;;di- - '
,:diameter excavation wall (unstable wall) , yes No NA
,B-ackfill las leen ad-equately compacted for full suport along tank length at S and 7 o'clock yes No NA
Date of pressure test after backfill to top of tank (before piping is installed)
:
,^":, fu,l\ !fuf n { ,t t _ certify that I inspected the above-named facility on (date): VZr/.<flnspector'sSignature: ,Xn-, ./ /lt/- n. t lj / ia:r#.Tr a
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Yes No NA
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Utah Department of Environmental Quality
UST Facility Site Plat
4002691Page2 of_
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