DERR-2024-006245

Ownership of Tanks Location of Tanks
WHITEWOLF HOLDINGS MOUNTAIN HOME LODGE
HC 65 BOX 124 6801 N 21000 W
MOUNTAIN HOME UT 84051 MOUNTAIN HOME UT 84051
Contact Name:#/Email:
SPCC Plan?: Yes No Last Fire Marshal lnsp:ATG lnfo
Complete for each tank.#a #t4 F-f fi ##
Capacity of iank (gallons):I Dn[)lDor)ioou
Orientation of tank:&a Wp c,&tnsY
.b--.--
Bottom of tank in contact with (soil,
gravel, concrete, not touching):bncre"ta ---f t
Substance stored:Prdvt Dias"al
Date last used/depth of product:AP# roi'^tlL r".iun lfr tn in
Type of spill prevention device:\l o.vk
-
_+
Type of Piping (Pressure or Suction):+
Yes NoDoes pressure piping have LLD:(EYes No (9Yes No Yes No NA Yes No NA Yes No NA
Spill bucket is clean, intact, etc.Yes Yes fNd)Yes (rud)Yes No Yes No Yes No
Type of overfill Prevention device:iLY[LnoL,)n
Overfill alarm (audible or visible) is properly located so delivery driver can hear or see it, and is clearly identified:Yes No NA-,
Pipe irans flex protection method
(Sump, CP, lsolated, Booted):Sr^r-rp
Containment sumps dry:Yes No I !t Yes ttto (ND No Ct(DYes Yes No NA Yes No NA Yes No NA
Sump comments:
Stage 1 Vapor Recovery:2pt one2pt 2pt Coax None 2pt Coax None 2pt Coax None
Pressure Vent Valve is on vents Yes NA Yes ftrP Nn No A})Yes Yes No NA Yes No NA Yes No NA
Secondary containment area
comments
Gomplete for each dispenser #l #L fr'3 #E E
Flex protection method (UDC,
Cathodic Protection, lsolated, Booted):Soil +cpnuele
UDC sump dry:No NA tB No NA ((d No NA Yes No NA Yes No NA Yes No NA
Fire valve anchored, located below
grade, and without ball valve:
No NA(9 @ No NA tgy' ruo NA Yes No NA Yes No NA Yes No NA
Comments:
Additional dispenser questions fr #####
Flex protection method (UDC,
Cathodic Protection, lsolated, Booted):
UDC sump dry: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
Yer: Nr NA Yes No NA Yes No NA Yes No NA
Comments:
Page 1 or I
Additional Comments
Utah Department of Environmental Quality
APST Equi ment Verification lnspection
rcs+ers
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Financial Responsibility (State Use Only)
FR Method Method OK?Yes No
Signatures
lnspected this facility on_.
Signalure:TI
O/O Signature:
Attach Tank lnfo Sheet to lnspection with any edits
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IS VdIsr
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Show locations of all buildings,
manways and identify each: su
(specify).
streets, tanks, piping, and dispenser islands. lndicate the product in each tank. Show locations of tank
bmersible pump (S), tank fill (F), ATG probe (A), interstitial probe (l), vapor recovery ff), capped plug (C), other
Comments:Y{
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