DERR-2025-004588

Utah DEQ Underground Storage Tank
lnstallation Notification Form
www.undergroundtanks.utah.gov
State Use Onlv
Permit Required? tr
Permit # 1632-20254
Base Fee S SOO
lnspection Fee*5200x 5 Stooo.oo
PST lnstall Fee $200 x 5 S looo.oo
Total S zsoo.oo
Date Approved & Paid
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Certified lnstallers/Technicians on project
NameThomas Dyckman Cert. # TLZgS Exp. Date g11t2o2t
Name Kelby Taylor Cert. # TL36Z Exp. Date
Name Cert. # TL Exp. Date
Tank Owner: Maverik, lnc.
Address:1g5 S State St #g00. SLC, UT. 94111
Contact Name:14s1k Stewart Phone#
Facility Name: Maverik #7g6
Facility Address:2376 S. 5600 W. West Vattey City, UT. g5390
lnstallation / Upgrade /Repair lnformation I est. Date work will commence:
Tank #1 rtRt (1B)3 QI 4 (3A)5 (3B) 6 (3C
Capacity 15k 10k 25k 8k 9k av
Tank Material FRP FRP FRP FRP FRP
Piping Material OPW Flex OPW Flex OPW Flex OPW Flex OPW Flex
Substance stored unleaded unleaded diesel ethanolfree premium DE
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
!nstallation of 3 UST's and all underground piping and 16 dispencers
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Mail completed form to:
DEQ/DERR
Box 144840
salt Lake city, Utah 847L4-484O
195 N. 1950 W. 1't Floor
Salt Lake City, Utah
Phone [phone]
Fax [phone]
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ENVIRONMENTAL RESPOHSE
& REMEDIATIOH
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