DERR-2024-006239

Page',l ot t Utah Department of Environmental euality
APST Equipment Verification lns pection
9oo08rr
Ownership of Tanks Location of Tanks
JOHNSON & MADSEN PROPERTIES INC DBA TEWAY SINCLAIR
POBOX227 655 W MAIN
DUCHESNE UT 84021 DUCHESNE UT 84021
Contact Name #lEmail
SPCC Plan?: Yes No Last Fire Marshal lnsp:ATG lnfo:
Complete for each tank.###
Capacity of tank (gattons)
Orientation of tank:
Bottom of tank in contact with (soil,
gravel, concrete, not touching):saadle
Substance stored:t|'rn
Date last used/depth of product:
Type of spill prevention device:
Type of Piping (Pressure or Suction)
Does pressure piping have LLD:Yes No Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA
Spill bucket is clean, intact, etc.:No No No No No Yes No
Type of overfill Prevention device:
ble)ivery clearlyOverlillalarmorvtstts(audible solocated delproperly candriver orhear see it,tsand identified:No NA
Pipe trans flex protection method
(Sump, CP, lsolated, Booted)6
Containment sumps dry:No NA No NA No NA No NA No NA Yes No NA
Sump comments:
Stage 1 Vapor Recovery:2pt None None2pt 2pt 2pt 2pt None 2pt Coax None
Pressure Vent Valve is on vents:No NA No NA No NA Yes No Yes No NA Yes No NA
Secondary containment area
comments:
plete for each dispenser
Flex protection method (UDC,
Cathodic Protection, lsolated, Booted):t{Pc
UDC sump dry:No NA No NA No NA No NA No NA No NA
es YesFire valve anchored, located below
grade, and without ball valve:
No NA No NA No NA No NA No NA No NA
Additional dispenser questions li #
Flex protection method (UDC,
Cathodic Protection, lsolated, Booted):
UDC sump dry:No NA No NA Yes No NA Yes No NA Yes No NA
Fire valve anchored, located below
grade, and no ball valve:
No NA No NA No NA Yes No NA Yes No NA Yes No NA
Comments:
Financia! Responsibility (State Use Only)
FR Method Method OK?Yes No
Signatures
lnspected this facility on
Signature TI
O/O Signature:
Attach Tank lnfo Sheet to lnspection with any edits.
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manways and identify each: submersible pump 1s;,1anr fill (F), ATG probe (A), interstitial'prol" trl, vapor recovery (V), capped ptug (C), other(specify).
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