DERR-2025-001563

Utah DEQ Underground Storage Tank
Installation Notification Form
www.deq.utah.gov /257
FacilitylD �.5b3 New UST Install
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Address:
Certified Installers/Technicians on project
Cert. #TL 013'7
Name Cert. # Tl C) '17
Name Cert. # TL O 'f 7 g-
Tank Owner:
Address:
Contact Name:
Facility Name:
Facility Address:
State Use Onl
Permit Required? O
Permit# _______ _
Base Fee $ 500
Inspection Fee* $200 x _ ..._$ __
PST Install Fee $200 x _ _$ __
Total .,__$ __
Exp. Date (J
Installation / Upgrade /Repair Information Est. date work will commence:
Tank# k
Capacity
Tank Material
Piping Material
Describe Details of Install/Upgrade/Repair in the box below (Submit a drawing/site map of work to be done)
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Mail completed form to: 195 N. 1950 W. 1st Floor
DEQ/DERR Salt Lake City, Utah
Box144840 Phone[phone]
Salt Lake City, Utah 84114-4840 Fax [phone]
Ver. 8/1/2016
UTAH Dl':.i=>Ai:iTMeNT of
ENVIRONMENT.�L QUALITY
ENVIRONMENTAL RESPONSE
& REMEDIATION
NO PERMIT OR FEES FOR INSTALL 3/3/25