DERR-2025-001448

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 801-673-3435
3075 Haun Dr. West Jordan, UT. 84088
Thomas Dyckman
Kelby Taylor
Golden Gate Petroleum
16580 Wedge Parkway Reno, NV. 89511
Golden Gate
132 E. Old HWY 6&50 Crescent Junction, UT. 84540
3 4 521
3k10k7k20k20k
FRPFRP FRP FRP FRP
diesel unleaded premium diesel DEF
OPW Flex OPW Flex OPW Flex OPW Flex OPW Flex
Installation of 3 UST's and all underground piping and 6 dispensers 5 highflows
Anthony Herrmann 775-850-3010
295
367
4/2025
3/2025
3/10/2025
5000751
132-2025-3
4 800
4 800
2,100