DERR-2025-000667

Utah DEQ Underground Storage Tank
State Use Onlv
lnstallation Notification Form
www.undergroundtanks.utah.gov
Permit Required? tr
Permit # L632-2025-2
Base Fee S sOO
lnspectionfee*5200x 3 S 500
PST lnstall Fee 5200 x 3 S 500
Total S 1,ZOO
Date Approved & Paid
* A ^^li^- ih -^^ r un ^^^+,-
D) #\ ll l[
Certified lnstallers/Technicians on project u lgJaa)t-e
Name Thomas Dyckman Cert. # TLZgS Exp. Date 4l2O2S
Name Kelby Taylor Cert. # TLSOZ Exp. Date 3t2O2S
Name Cert. # TL Exp. Date
Tank Owner: Smiths Food & Drug Centers
Address: 1550 S. Redwood Road Salt Lake City, UT. 84104
Contact Name: Mark Ellis Phone#
Facility Name: Smiths #153
FacilityAddress: 10305 S. 1300 E. Sandy, UT. 84104
lnstallation / Upgrade /Repair lnformation I est. Oate work wi!! commence: March 17,2025
Tank #1 2A 28
Capacity 20k 10k 8k
Tank Material FRP FRP FRP
Piping Material Flex Flex Flex
Substance stored unleaded diesel premium
Check if upgrade or repair only. E (Describe details below)
Describe Details of lnstall/Upgrade/Repair in the box below (Submit a drawing/site map of work to be donel
lnstallation of two UST's and all underground piping and 7 dispencers
Fltrntrt\/trn
JAISTII-ZIZ5
Ertvirorrrttuttlal Ht:spotrst &
rlurnr:tliitlittn
Mail completed form to:
DEQ/DERR
Boxt4484O
salt Lake city, Utah 841L4-4940
195 N. 1950 W. 1't Floor
Salt Lake City, Utah
Phone [phone]
Fax [phone]s3
lJ?4i'i s,rp,4nTt1 g 1..t1 4.f
E ltJV I Fl$Il l-1 ENT& L Q l.,,n L t
-iY
ENVIRO}*ME NTAL R ESFONSE
& REHEDIATION
Ver.8l7120!6