DERR-2024-006246

Utah Petroleum Storage Tank Program
tion for Certificate of Com liance Facility ID#7ooo3r6
PST Owner Information PST Facility Information
DESCRIPTION OF' PETROLEUM STORAGE TANKS
TANK/LINE TIGHTNESS TEST Indicate Pass or Fail for each tank and line tested. Include a ofthe test.
TYPE OF F'ACILITY
! Marketing facility, or non-marketer with facility average monthly throughput greater than 10,000 gallons.
Sl Non-marketer with facility average monthly throughput less than 10,000 gallons.
CpMPLTANCE WrTH PST REGULATTONS
A Xt Petroleum Storage Tanks (PSTs) at this facility have been registered.
fl Registration fees and Petroleum Storage Tank Fund Fees have bJen paid.
Are your PSTs currently in compliance with all Federal, State, and Local PST regulations, including applicable Fire Code?
fi Yes n No If uNo" describe items of non-compliance:
f 72o1
ownerNamel 6\ S/-r Ttnpsatf L I c Name:
Address: l3l<L x). /4o.All/*u Alul Address: 7.LqS I S. tluJv (7
City:DL).-ln^, r.il-State: Q p^Zip:73ttt2 City: Ata,lps*+State: UT Zip: Rt/ctt /
Contact: S L.*,- ao7*.e Phone: 9OS t( + ?z lContact: 3l*.-- S2et Phone: '/OS 6:
Tank # I I
UST or AST A8,T
Date Installed la co I
Capacity lL(
Substance Stored Aar-
Tank #
Tank Test
Line Test
PRf,VIOUS POLLUTION INCIDENTS
ftl Complete the Previous Pollution Incidents form to indicate whether a pollution incident has occurred at the facility.
FINANCIAL RESPONSIBILITY MECHANISM DECLARATION (check one only)
fl I choose to participate in the Environmental Assurance Program (psr Fund) *.
o Indicate the financial responsibility mechanism to be used for cleanup costs not covered by the Fund.
o Indicate the number of non-r"rgJlated petroleum storage tanks at the facility.* Non-regulated PSTs at the facility may be required to participate in the Environmental
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another Financial Responsibility mechanism for the PSTs at this facility.
o' Indicate the financial responsibility mechanism to be used:r (For self-insurance or guarantee) Indicate your company's fiscal year end date:
o (For Insurance) Indicate the date the policy is renewed each year:
Assurance Program.
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 ofcoverage for the new tanks.
I certify under penahy of law that the made by me are lrue and correcl.
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Owner/operator Sigrature Date Signed
CoCapp 1022