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HomeMy WebLinkAboutDERR-2025-001216PST Owner Information Facility ID# PST Facility Information Owner Name: Facility Name: Address: Address: City: State: Zip: City: State: UT Zip: Contact: Phone: Contact: Phone: DESCRIPTION OF PETROLEUM STORAGE TANKS Tank # UST or AST Date Installed Capacity Substance Stored TANK/LINE TIGHTNESS TEST Indicate Pass or Fail for each tank and product line tested. Include a copy of the test. Tank # Tank Test Line Test TYPE OF FACILITY Marketing facility, or non-marketer with facility average monthly throughput greater than 10,000 gallons. Non-marketer with facility average monthly throughput less than 10,000 gallons. COMPLIANCE WITH PST REGULATIONS All Petroleum Storage Tanks (PSTs) at this facility have been registered. Registration fees and Petroleum Storage Tank Fund Fees have been paid. Are your PSTs currently in compliance with all Federal, State, and Local PST regulations, including applicable Fire Code? Yes No If "No" describe items of non-compliance: PREVIOUS POLLUTION INCIDENTS Complete the Previous Pollution Incidents form to indicate whether a pollution incident has occurred at the facility. FINANCIAL RESPONSIBILITY MECHANISM DECLARATION (check one only) * Non-regulated PSTs at the facility may be required to participate in the Environmental Assurance Program. I choose another Financial Responsibility mechanism for the PSTs at this facility. •Indicate the financial responsibility mechanism to be used: •(For self-insurance or guarantee) Indicate your company’s fiscal year end date: •(For Insurance) Indicate the date the policy is renewed each year: The Certificate of Compliance cannot be issued until all documents have been submitted and the mechanism has been approved. If the mechanism has already been approved, submit documentation of coverage for the new tanks. I certify under penalty of law that the above representations made by me are true and correct. CofCapp 1022 Utah Petroleum Storage Tank Program Application for Certificate of Compliance I choose to participate in the Environmental Assurance Program (PST Fund) *. •Indicate the financial responsibility mechanism to be used for cleanup costs not covered by the Fund. •Indicate the number of non-regulated petroleum storage tanks at the facility. Owner/operator Signature Date Signed 100223 State of Utah Fuel Network TSOB 4315 S 2700 W Utah 84129 Brett Gurney 385 602-4872 Logan UDOT 730 W 200 N Logan 84321 Brett Gurney 385 602-4872 unleaded diesel 1 Pass Pass Pass Pass 2/04/2025 Fuel Network Program Manager (12,000 split tank 5,000 unleaded 7,000 dieselASTAST 9/23/2025 9/23/2025 5,000 gallons 7,000 gallons