DERR-2024-006465

Utah DEQ Underground Storage Tank
lnstallation Notification Form
ZOOOGT 6 www.undergroundtanks.utah.sov
State Use Onlv
Permit Required? tr
permit g 7632-2024-3
Base Fee S soo
lnspection Fee* s200x 5 s 1000
PST lnstall Fee S2oo x 5 S looo
Total 52500
Date Approved & Paid
* A -^ri^- r^ -^l LiJil^^iI;^-J-
I
Certified !nstallers/Technicians on project
NameThomas Dyckman Cert. # TL 0295 Exp. Date 41112025
Name Kelby Taylor Cert. # TL 367 Exp. Date 312512025
Name Cert. # TL Exp. Date
Tank Owner:7-Eleven
Address: p.O. Box 71 1 Dallas ,TX.75221
Contact Name: MarC Westfall Phone# [phone]
Facility Name: 7-Eleven Store 36335
FacilityAddress:g30 East 100 North Nephi, UT. 9464g
lnstallation / Upgrade /Repair lnformation I Est. Date work will commence: 611012024
Tank #4 5&6 7 8&9
Capacity 27k 20k 27k 27k
Tank Material 2OK RUL / 7K REC 8k PUL / 12k Diesel 2OK RUL / 7K REC 20k Diesel lTkDEF
Piping Material Flex Flex Flex Flex
Substance stored
Check if upgrade or repair only. E (Describe details below)
Describe Details of tnstalUUperade/Repair in the box below (Submit a drawing/site map of work to be done)
lnstallation of 3 UST's and all underqrounq Dioino and 4 disoencers
'..1,, :.\. :. : .r, i i
lnsltllttlon / Up6rutlc /Htpuh htfornmllon f st, tJote work will rommrnte: 8f 1OEO24
tanklt 4&7 5&6 8Bg : . r :
Ii-.rp.rc,ty 27\ ?ok 27k
Idnk Mdic. u1 FRP DtuV t-RP D,J./ FRP DtLrpirinflMiteriir Fter ,,"* i,* Addgd by PKL
\lrt)(lanie lloied /ur'.i.'t "'1 ,lLu aI l:..1 i'ii l. {!.,
[hcck rI upgrar]t'o, rupar u'ly. O (Durrrrbr: tlctarlr bulcrw]
oesllbeoet.ll5otln;tall/Up3redc/Repairltrthrhorbelw(submltadrawi.|&/'lleNEpolwltobed.
Mail completed form to:
DEQ/DERR
Box 144840
Salt Lake City, Utah 84LL4-484O
195 N. 1950 W. 1't Floor
Salt Lake City, Utah
Phone [phone]
Fax [phone]
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F l\r\.lr?O i"J H r l''lT.& L i} i.ii l- I 'T .f
ENVIRONMENTAL RESPONSE
& REMEDIATION
ver. SlL/2016