DERR-2025-001855

Utah DEQ Underground Storage Tank
I nstallation Notification Form
www,undergroundtanks.utah.gov
State Use Onlv
Base Fee S 500
lnspectionFee*5200x a S 800
PST lnstall Fee 5200 x + S soO
Total S 2,100
DateApprov"aaeriaZ M
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Certified lnstallers/Technicians on project lJ t-:j-ru
NameThomas Dyckman Cert. # TLZgS Exp. Date4 DO2S
Name Kelby Taylor Cert. # TL36Z Exp. Date3l2OzS
Name Cert. # TL Exp. Date
Tank Owner: Golden Gate petroleum
Address:16580 Wedge parkway Reno, NV. 99511
Contact Name: 4p16onv Herrmann Phone# [phone]
Facility Name: Golden Gate
Facility Address: 1A2 E. Old HWy 6&50 Crescent Junction, UT. g4540
lnstallation / Upgrade /Repair tnformation I Est. Date work will commence 3l1Ol2O25
Tank #1 2 3 4 5
Capacity 20k 20k 7k 10k 3k
Tank Material FRP FRP FRP FRP FRP
Piping Material OPW Flex OPW Flex OPW Flex OPW Flex OPW Flex
Substance stored diesel unleaded premrum diesel DEF
Check if upgrade or repair only. E (Describe details below)
Describe Details of lnstalUUpgrade/Repair in the box below (submit a drawins/site map of work to be donel
lnstallation of 3 UST's and all underqround pipinq and 6 dispensers 5 hiqhflows
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Mail completed form to:
DEQ/DERR
Box 144840
Salt Lake City, Utah 84Lt4-484O
195 N. 1950 W. 1't Floor
Salt Lake City, Utah
Phone (80U 536-4100
Fax [phone]
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ENVIRONMENTAL RESPONSE
& REMEDIATION
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