DERR-2025-004853

Facil ro 'T0oo 3Utah Department of Environmentat euality
Permanent Glosure lnspection
P e of
Owners of Tanks Location of Tanks
Owner Na Name
Address Address
State ZiState UT
Contact Phone Contact Phone
ks Closed.onal f tanks.Tank No.Tank No. ?-T No.Tank No.
llon
Material of FRP m etc.
Substance
Date Last Used
Date Perman Closed b
How Closed ln Seln Place Cha
nal Number of tankso Closed Tanks:New Tanks:Final Number of tanks: OClea
UST Remover:a-{1 Cert. #: TR E Date 25
,^' \\tlGroundwater/soil Sam Cert. #: GS eb Date 7
has an Closure PlanOwne No of the Closure Plan is on siteA
Product removed No Dis Site:
removedSlu NoB Site:
Tanks cleaned No B Rinsate dis
ere inside tank obtainedNonatmos tr ln LEL or %obtained a)
secured in I siteandProduct lines were: tr Removed. Dis
Tank site Soil di site: \\ I I
Site As
PID or FID meter read show readi locations on the site
Meter Gain or s Calibration
Soil Contamination is evident:No De of Contamination: 0-3 Feet Greater than 3 F
ndwater contamination is evrdent: yes to WaterDe ab Surface direction:
Number of collected GW Soil USC Certified Lab:
Land Use of E Commercialarea:OtherResidential n I
sample grouped together. lnclude any samp taken by theSam
sam
the samo analyslb can
and the site
Sam num Substance in Tank J e ounds ana MethodsAna
icate the and direction to the on the siteShow
Restdences Commercial Buildin LineP Active Water Well
Surface Water Sewer Line Water Line Natural Gas Line
Tel one Line Electrical Line Storm Drain Other:
lnspector observed collection of samples:
Contaminated soil was over-excavated:Yes
No
No
lnspector collected and submitted duplicate samples:
lf yes, confirmation samples were collected:
Yes
Yes No
me 0t e.that I the facili on rt
nature:r Cert. #: Tl
Closureinsp090B,doc
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Facil ro €Do3zUtah Department of Environmental euality
UST Facility Site ptat r)l/of
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submersible ATGpump,fiil, probe,vapor Foretc.lndclosures:icaterecovery,
the ndicate of DPI or
oflocations tank each:manways
and of each collected certifiedthedepthsampleby
the product in
Show locations of
the type (soil, GW, USC), location,
Comments
12k Reg 12k Diesel 12k Reg