DERR-2025-001207

Utah Notification for Aboveground Petroleum Storage Tanks
Division of Environmental Response and Remediation Phone# [phone] STATE USE ONLY Underground Storage Tank Section Fax# [phone] Facility ID#: P.O. Box 144840 Email: [e-mail] Date Received: Salt Lake City, Utah 84114-4840 Web site: deq.utah.gov Data Entry Clerk Initials: __
This form must be completed for each location containing aboveground petroleum storage tanks (APSTs) that are regulated
by the State of Utah.
I.r Ownership oftank(s)
Owner Name [/WJV U\\M)V I I lJtt'II I ()~f)IV
Mail(ng A,�\�ress
City . r,v· I I\ '
Contact \;'Ji/L ;t
Phone nl tl?v
E-maiiC\.J,\'\u'. I''
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State Fry \.l S,
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'11 I Cell# n "llf( I 1-effiu0v1 I In/
Type'C!f Noiification
Zip i:l1J1£l]
II, Location of tank(s)
Facility ID# {�Wnew �tion .
Facility Name _l(( \\)(} \li(IIY,I _TlnlV/
Street Address' 11'.vil 1'17 llt,W \1 1 ' ·
County0-f.W f�lrttjl City(()\'\Vlt\n
Facility Phone #
Latitude: Longitude:
IV, Other
Zipl/'Jf/JOl
'IX') New Notification 0 Amended Notification □Federally regulated underground storage tanks are at
i this location. If so, please enter the Facility ID assigned inb 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 Owner VI.Type of Facility VII.ExemptCommercial □Auto Dealership □Railroad □Commercial Airport(fue/ing}Private □Contractor □Residential □Farm/Agriculture□Federal Government □Federal Non-military □Trucking or Transport □Petroleum Distributor/Refiner /SIC□State Government □Federal -Military □Utilities Code 2911 or 5171) □Local Government � Gas Station □Other (explain) □Oil or Gas Production and□Tribal Government □Industrial Gathering□Heating Oil used on premises□Less than 501 gallons
VIII.Contact Person in Charge of Tanks
Name: E-mail:Address: Phone Number (Include Area
Code): Job Title:
' IX.Financial Responsibility
I plan to meet the financial responsibility requirements by using the following mechanism(s}: (checkaflthat apply}
Bond Rating Test □ Local Government Financial Test □ Surety Bond Commercial Insurance □ Risk Retention Group □ 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.
CE.cJ 8thL� 11 Dot v, .s
Nam� and official title of owner or owner's
Authorized representative (Print)
Page 1
/57,4;;".? ;,,_,1 . ,.
'5(�q-p_3 Date Signed <
Version 10.12.2021V1