DERR-2025-003767

Utah DEQ Underground Storage Tank
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Certified lnstallersflechnicians on project
Name Ce,a* ,)6( d;r'r-cert. f rL D0b 6 Exp. Date P /rc/"a
Name a nb{- D& War I cert. f rL Oq ZCI Exp.Date Z/tf/Zl
Name Cert. f TL Exp. Date
Tank Owner:{ norrJ ,(
Address: 3U"q E, nAitIr ol .L DA * lqo
Contact Name:cvt- T tq h,,{ lJtll Phone# frOl- 113 - ZIH
Facility Name:l now b irL
Facility Address:q3 x5 5 now birol ( { r {IR
[nqtallation / Upgrade /Repair Information I Est. date work will commence:
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Tank #Z
Capacity ta, o00 4 .w0
Tank Material FkY a)
D- a,/. ?12'
€w D,k
Piping Material h.t,r. fltv
Substance stored o9L r IAIL
Check if upgrade or repair only.(Describe details below)
Describe Details of lnstalUUpgrade/Repair in the box below {Submit a drawinB/site map of work to be done}
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Mail completed form to:
DEO/DERR
Box 144840
salt Lake city, Utah 84114-4840
195 N. 1950 w. 1$ Floor
Salt Lake City, Utah
Phone [phone]
Fax (80U 359-8853
F-rrvttttttttttttlal Re sPonse &
Rcltlediation
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