DERR-2025-004917

PST Owner Information
Facility ID#
PST Facility Information
Owner Name: Facility Name:
Address: Address:
City: State: Zip: City: State: UT Zip:
Contact: Phone: Contact: Phone:
DESCRIPTION OF PETROLEUM STORAGE TANKS
Tank #
UST or AST
Date Installed
Capacity
Substance Stored
TANK/LINE TIGHTNESS TEST Indicate Pass or Fail for each tank and product line tested. Include a copy of the test.
Tank #
Tank Test
Line Test
TYPE OF FACILITY
Marketing facility, or non-marketer with facility average monthly throughput greater than 10,000 gallons.
Non-marketer with facility average monthly throughput less than 10,000 gallons.
COMPLIANCE WITH PST REGULATIONS
All Petroleum Storage Tanks (PSTs) at this facility have been registered.
Registration fees and Petroleum Storage Tank Fund Fees have been paid.
Are your PSTs currently in compliance with all Federal, State, and Local PST regulations, including applicable Fire Code?
Yes No If "No" describe items of non-compliance:
PREVIOUS POLLUTION INCIDENTS
Complete the Previous Pollution Incidents form to indicate whether a pollution incident has occurred at the facility.
FINANCIAL RESPONSIBILITY MECHANISM DECLARATION (check one only)
* Non-regulated PSTs at the facility may be required to participate in the Environmental Assurance Program.
I choose another Financial Responsibility mechanism for the PSTs at this facility.
•Indicate the financial responsibility mechanism to be used:
•(For self-insurance or guarantee) Indicate your company’s fiscal year end date:
•(For Insurance) Indicate the date the policy is renewed each year:
The Certificate of Compliance cannot be issued until all documents have been submitted and the mechanism has been approved. If
the mechanism has already been approved, submit documentation of coverage for the new tanks.
I certify under penalty of law that the above representations made by me are true and correct.
CofCapp 1022
Utah Petroleum Storage Tank Program
Application for Certificate of Compliance
I choose to participate in the Environmental Assurance Program (PST Fund) *.
•Indicate the financial responsibility mechanism to be used for cleanup costs not covered by the Fund.
•Indicate the number of non-regulated petroleum storage tanks at the facility.
Owner/operator Signature Date Signed
Kilgore Companies, LLC Kilgore Corporate Office
7057 W. 2100 S
Salt Lake City UT 84128
Lee Ware 801-831-7402
7057 W. 2100 S.
Salt Lake City 84128
Lee Ware 801-831-7402
#1
AST
2007
12,000 gallons (8,000 g = Diesel Fuel & 4,000 g = Regular Unleaded Fuel
Diesel Fuel and Regular Unleaded Fuel
X
X
Completion of Tank and line tightness testing is needed. NOTE. Services are scheduled.
X
X Company Responsibility
0
08/23/2023
4002421