DERR-2024-006242

Ownership of Tanks Location of Tanks
LIBERTY CORNER STORE LLC LIBERTY CORNER STORE LLC
PO BOX 268 6982 N 9500 E
LAPOINT UT 84039 LAPOINT UT 84039
Contact Name #lEmail
SPCC Plan?: Yes No Last Fire Marshal lnsp:ATG lnfo
Gomplete for each tank.#a #"<fr fr #
Capacity of iank (gallons):io. nnr-.r lo DtY)Q,rc
Orientation of tank:hie5.t-
Bottom of tank in contact with (soil,
gravel, concrete, not touching):Crnerele-J
Substance stored:Qai,*ni.n T)tPSe,
Date last used/depth of product:
Type of spill prevention device:S -+Type of Piping (Pressure or Suction):
-Does pressure piping have LLD:Yes No ep Yes No At Yes No u,Yes No NA Yes No NA Yes No NA
Spill bucket is clean, intact, etc.No No No Yes No Yes No Yes No
Type of overfill Prevention device:
Overfill alarm (audible or visible) is properly located so delivery driver can hear or see it, and is clearly identified Yes ruo @\
Pipe trans flex protection method
(Sump, CP, lsolated, Booted)gDn^A --->
Containment sumps dry:No NA No NA No NA Yes No NA Yes No NA Yes No NA
Sump comments
Stage 1 Vapor Recovery:y' ttone '2pt None 2pt Coax None 2pt Coax None 2pt Coax None
Pressure Vent Valve is on vents:No NA No NA No NA Yes No NA Yes No NA Yes No NA
Secondary containment area
comments:
Complete for each dispenser E a\)L #f ##
Flex protection method (UDC,
Cathodic Protection, lsolated, Booted):t/Dc (^DC
UDC sump dry:@s No NA No NA Yes No NA Yes No NA Yes No NA Yes No NA
Fire valve anchored, located below
grade, and without ball valve:
(9 No NA {9 No NA Yes No NA Yes No NA Yes No NA Yes No NA
Comments:
Additional dispenser questions ####tr #
Flex protection method (UDC,
Cathodic Prolection, lsolated, Booted):
UDC sump dry:Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA
Fire valve anchored, located below
grade, and no ball valve:
Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA
Comments:
Page 1 or I Utah Department of Environmental Quality
APST Equipment Verification lnspection
90(I)3+r
Financial Responsibility (State Use Only)
FR Method Method OK?Yes No
Signatures
lnspected this facility on_.
Signature:TI
OiO Signature:
Attach Tank lnfo Sheet to lnspection with any edits
Additional Comments
Y^[c LoFz 4uoo34l
APST Facili Site Plat
NORTH
Disy cn:ers
Qr S\ore-
firanitroo
r'"P3ct-
k
Ju\
pa.
Show locations of all buildings, streets, tanks, piping, and dispenser
manways and identify each: submersible pump (S), tank fill (F), ATG
(specify).
islands. lndicate the product in each tank. Show locations of tank
probe (A), interstitial probe (l), vapor recovery (V), capped ptug (C), other
esComments:
S
fr
F
S
Y
v
o
?
S
pierrJ B,coo
r
S
?reln lo,
P
./u