DERR-2025-004584

Utah DEQ Underground Storage Tank
Installation Notification Form
www.undergroundtanks.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. Date 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 # _____________________
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
Petroleum Installation Specialists
Thomas Dyckman 801-673-3435
3075 Haun Dr. West Jordan, UT. 84088
Thomas Dyckman
Kelby Taylor
Maverik, Inc.
185 S State St #800. SLC, UT. 84111
Mark Stewart
Maverik #786
2376 S. 5600 W. West Valley City, UT. 85390
1
15k
unleaded
2
10k
unleaded
3
25k
diesel
4
8k
ethanol free
5
9k 8k
premium DEF
FRP FRP FRP FRP FRP
OPW Flex OPW Flex OPW Flex OPW Flex OPW Flex
Installation of 3 UST's and all underground piping and 16 dispencers
295
367
3/18/2027
(1A)(1B)(2)(3A)(3B)6 (3C)
5
5
1000.00
1000.00
2500.00
x
1632-2025-4
4002701
6/13/2025