DERR-2025-004499

Utah DEQ Underground Storage Tank
Installation Notification Form
www.ĚĞƋ.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.Ěate 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 #No permit required
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
4002407
R10D, LLC Steven Moreland
Steven Moreland 928.231.1531
Wickenburg, AZ 85390
Steven Moreland
12839652-2201 11/30/2027
Walmart Inc.
2101 S.E. Simple Savings Drive, Bentonville, AR 72712
Sara Gallien 479.258.2364
Sam's Club
11278 South Jordan Gateway, South Jordan, UT 84095
T1
20,000
Fiberglass
Double wall flexible plastic
Gasoline
Installing four new fueling dispensers with associated piping and canopy.
T2
20,000
Fiberglass
Double wall flexible plastic
Gasoline
T3a
8,000
Fiberglass
Double wall flexible plastic
Premium Gasoline
T3b
12,000
Fiberglass
Double wall flexible plastic
Diesel
✔
✔
07/07/2025