DERR-2024-006295

A\
UST Location Contact
State
Phone #
Facility Name
Street Address
Owner Name
ttr
State zip.ive l
)rm.
Gr/Tank 2 Tank 3 Tank 4
[.€trType of or AST)
irrt oFt >rStatus (ln use, temporarily out of use, etc.)
k5-affr5Date ol last use (if not cunently in use)
rw lqaSDate installed
l'lrrtrr^r-..h,\Substance stored
3ffi*9Capacity-13Tank material ol construction , composite, etc.)
3Piping material ol construction (flexible, FRP' etc.)
.a rtl cfisuction, gravity, etc.)Piping type (
aY^\{\;lm k\Depth of liquid in tank
haiili-rrr^r Or IType ot liquid in tank
I
s,I
uh\
€55
Xsoa 0rca be\otr3rffiS_juen\ L;rrcs
(,3)t
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rr, GQ[5lnspected
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- \rT'CrDistribution: White-DERR, Yellow-lnspector ustastinJo.wpd 9/99
UTAH UST PROGRAM
UST/AST lnformation
Facility lD No. /Oo0 Sla
ll. Location of Tank(s)l. Ownership of Tank(s)
lll. Tank lnformation
Number ol tanks present: \
b\\
c1€r
-fCY \ L_-\-\r
ffiECHURCHoT
,JESUS CHRIST
OFLAIER-DAY
SAIMTS
PFTYSICAL FACIUTIES
Utah Areas
61 East North Temple Street
salt l-ake city. ulah 84150-0001
UTAH DEPARTMEI{TOF
EilVlRnililFttlTAL 0tlALlW
JAtl A6 Nst nu
OIV. (}F EiIUIBONMEiITAL
RESPONSE ANO RFMFN'ATION
Kenc P. Gray (5?{.-9 rc O)
Ttre Bureau of EnvirorunentaiL Response and Renediation
UST Section - ExemPt Tanks
288 North 1450 l.Iest
P. O. Box 16590
Salt Lake CitY, Utah 84116-0590
RE: REQUEST FOR CERTIFICATE OF H(ruPTION FQR ITIIDERGRQUND TAI{K
Dear Mr. GraY:
we feel this tarrk should receive a certificate of Exemption. It is used
exclusively for storing heating oil for consr:mption use on the premises'
Sincerely,
Y/\d 3l & *
Regional Manager
(80r) U+o-2652
Enclosure
Poulton Insurance Agency
3785 South 700 East, Suj-te 20
Sa]-t Lake cj.ty, Utah 84105
su&@oE
il oz I
'.TH|S CEFnFICTIE rS TSSUEo I IATTEB OF I}TFONMATION ONLY ANO CONFEBS
!{O RIGHfii UPON THE CERTFII. , . i HOLDEH. THIS CEHTIFCETE DOES iIOT AUENO.
E(TENO OB ALTER THE COVE8AGE AFFOAOEO BY lHE POUCIES EELOW
COMPANIES AFFOROING COVERAGE
Hry A Lunbermens Mutua1 Casualty Company
coMPAr{Y oTETTEN g
t
PROOUC=n
@oE
lxslJF@
The church of Jesus
Latter-day Saints
50 East North Temple
sa1t, Lake city, utah
Christ of @IIPANY
IET]EB
S treet
84150
c
@UP NY
LETTEB D
COUPATY
LETTEB
THIS IS TO CEBTIFY THAT THE POUCIES OF INSURANCE USTED SELOW HAVE BEEN ISSUED TO THE IMiUBED NAMEO ASOVE FOR THE POUCY PEErcD
INOICATED, NOTWITHSTANOING ANY REOUiREMENT, TERM ORCONOMON OF ANY CONTHACf OR OTHER OOCUMENT }YIT}I RESPECTTO WHICH THIS
CER'I]FICATE MAY SE ISSUED OR MAY PERTAIN. THE INSURANCE AFFOROED BY THE POUCIES OESCRIEED HEREIN IS SU&jECT TO ALL THE TENMS.
E(CLUSIONS ANO COND|TIONS OF SUCH POUCIES. UMMS SHOWN MAY HAVE SEEN REDUCED BY PAIO CI-{IMS.
co PCTUCY EFFEdTV€ P(rl-lcr lxPtRlnOX.
oaTE (ux,,oom i DA'E (r.Mroo/YY)^l.l.
ul'rr !!!!!1Q!trt!!gTYPE OF IIISUR NCE POIJCY XUIE€E
_GaEFrL UASrUTY
COMUEFCIAL GANEHAL UAAIUTY
A--j Pol lutiolr Liabjlity
GE{EBAj. AGGFEGATE - ooo
PFOOUCTS4OMP'OPS AGGFEG TE:'ffi-
ffi HEtflnciden€ 1,000
: FIRE oAa GE ( rr d'. ftll ! 5
uEDlCrt EXPEISE (r,ry dr. r.tgll r s
AGOEI'.
AUTOTOBII.E LIABIUTY
__._ *r ^60
,,. AL! OIVNED AUTOS
SCIIEDULEO AUIOS
. HIREO AUIOS
r{oN-owNEo AuTos
GARAGE UAAIUTY
. coMSrNo
- SINGLE, UUTT
800rLY
INJUFY a
800rLYINJUFIY t
PHOPATY
OAMASE s
EXCESS UlarUTY
'- -- '-EicH---
-/tscFEGArE, OCCUAFENCE,!5
SIATUTORYwoErER's corPExs Ttoti
Arao
EUPLOYEAS' U EIUIY
3 {EACH ^CCIOEI.I]
(DTSE SE--rOUgY UMO
t (DTSEASE-€{CH EUPLO rE5
OTHEF -Fouutiori' iniid-eit ll- in cluding cleanup costs, arising out of:
oEscarprrora oF opEBlTro.asJtocarrol-irrvExrclEsdEsrnrqrrorsrp€cuL rrEr.lr Ownership
aboveground storige tanks, per schedule on-
or operation of underground/file with the insurance comPany -
CERTIFICATE HOertir-icate Eolder is an Additional
sured.
Phys ical Facilitj.ef Depaltmeat
50 East North Temple streetsalt Lake City, Utah 84150
SHOULO AT.IY OF THE ABOVE OESCNIAED POUCIES 8E CANCELTTO EEFORE THE
D@IRATION OATE THEBEOF, THE EiSUING COMPAfiY ffLL ENOEAVOR TO
nel- -6lL olvs warrEN irorcE To rHE cEHnFcATE HoLoEF NAnEo ro rHE
IEFT. aUT FAILURE TO UAIL SUCH OnC€ SHA!! ITTPOSE llo oauGATI9N oR
UAAUTY OF ANY KINO UPOI' THE COMPANY.ITS AGE TS OA NEPHESENTA?WES.
t{
ACORD 25-S .=?-^l'r.:lil: =?!? =!:...." . ' :t'rr!t- i;ira'-r
rME
,--X-.; usreE-occuR.:3Yl 481 939-00
: . owNER'S t COr{TBAgIof, S Pf,OT..
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OTHER THAN U AAELLA FOAU
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cf r:[fcl+
tgar
l.df.doi b rtqrtd t *rl lr k d t'la.frqrd lll*r{d
trr! h..tlr d to la.. rllrihLd raa.tE dtE J.ru.lr l' tt7+ fi
t,t &t trr crqri.. ct Lt l, 15, dora a'. boogttt ho lD dr.t I., t'
rS. th. illcnldi'r ltqr-- a tquH r, lGidr 02 d fb n -st .
Cq vabn.id Faaoy.., fd, (iC8Al. r.trnaa
Ifr p,lr!t, Fr?o.. ol fi tEin d.l Fggrrtt lt b boaa rn.rbra
Liaatqri E*a ird ta q har. tb.td Padarn g hodqra raalE l.
!b.rp.od trattulnb .don tlu p.ovU.rll b.baLdon llol$.,
!! d.t . rEdl' q h fl. .b..ica ot tudl rlcoda, ,o|, b[rLdoa, Lld, 6
rEtadixr.
Who ll.t Ldtly? s..do.r goc2 ot RCFA, .t .r {rd, ltqtit. irn, dt..
ar€rnpbd, oiia6 ol urdolllourd irnL dral ltor! raCdad tJbcrncaa iarn
mtity d8igraEd Stita o. lo.al aCpndor ol ha .ri.rrEa ol tEir tar*& Ornat
mcaru-
d ln lha Gara d n utdar!.qlld Srixa trll ln uaa qr i{olllt$ar 6, l$t' ,
b.qrght hD uaa dr. fil d6, .n, FDn rtE osn ]t l,d-!rq,ld c.!ft
Enk u!.d lq fir !E{r, u.., E ditpri.&rC d tadd rlbo,r, lrd
b) In 6. c... of rt ud]uqlid l!.q. E* h l'. t b.r l5.ntb?t
tX4. ful rE loqpr lt lI. ql tt8 dr.. lr! partqt ltlo atxd rrdl d(hrrdlllt balo.€ d'ra dlcaidnuairn ol la ur.
cl ll dr SEi {anq !o .tqui,t., rtt hdlty fi hl lfi,.'!qr n, dsler
! harv inbrn.ron o. irk ryrEftr.ur (ot*t ryr d.d u* hb'tn liqr ,!adl
D b. hdtrd.d),
lryld T.nb /lr! [Elu-d? Lhd.rltDuld ab,T. trnt L dalh.d s rtr o
a.lmurrdo.r of t nt
'l.t(tlLut
d D Go.ltin !n Elli'j.don ol't CdiLd
!6.Em..,'rrd (a *ioa. volune (ridtJdng qIr.qad t ddlrcrd ,pino, il
'lo'a or trsa ba.dari he oGurd. So.tx aE rFlaa arl uarda,glqJrld tI*! tEilg:
t. G!.o[,r., ut.d dl, I di.xt lL.l, l,d Z |ttdutsid clt at!. P.riddaa,
hrtiddca q lurnipE"
Wrl ?r*. lrt ErCud.d? T.*. rllmrrd lhci lha elumd.ri ltol tlq.d
i, nodfc.rirG Ot tnL ardud.d to.i lDdt r|bn tu
r. hm a ndd.ndd n {ll ol r,!O0 odloi. or La. Egadu uld b tEtlg
,t!E lud ha rE ra!. rrrdd P(!Foad:
Z trnka ua.d fg, rE irlg lr.atle oil fr. coturrPivr u.. qt ,L Pord.-i:t aEtd;
cl^lr rb1 rl*.it
gqfid dryaoa br{(. $at conlain ,.cddad sbaLricat. Tlit indudaa arry
irbrucr do-ftrd rr tu3(hL h tadiolr 10t 04) ot n! Co.rtg.drrrd|
Env|! rrod R.a9dr.., Co.nFi .liot nd U-atV Aar ol tlo (CERCL )'rifi
tra a!c.#r ol fll tlJb.rioa m'.rd ra hE!61 rrta undar Elbdd. c
FCRA il rD iiCub Dr!i.l.m, .,C., sr- C t tt bdli t-iF, tli.h i. .
lqrd r a[|E! 6riEl oa ttrFrort alE PIEF (tO gag[aa Fr.atrrll
rn r4., Frd. Fr qrr1 h.n .D.oIt ).
tlr'tfc lct r? S.rd co.rPL[d lb,lnl E
UTAH DEPARTMENT OF HEAL?H
BUREAU OF ENVIRONMENTAI, RESPONSE E REMED.
288 N. 1450 W., P.O. EOX 16590
a trd€E*t( dodrr E6a (lnaldm lillitE lt[] [odtrd u'r('.t lh. ]L!rd Gtt
HDdfi. S.r!r, Ad ol rS, o. trr. lffiu. Liquid Plrtn S.lr,ldo,lm,a
rri6. n nE .D lrirfrr EiU rtrrhad ulr. S *G
A rrb angorlrItta, Pi!t, Ftol' 6 baqrr;
C tEttr E c@rr oqrEurn ttlrma;
t t*iEEi rEt.rtu:
a. lilla lTa a llaEe odtiare fi- AGtr ttaE D d d era
IldrCo,t.rd ladrho e..da!:f tgra !]tta tiud h lt ulallolrr t,tr (fdl aa l b[allllrt' cla.
irnGliho, &tlt, adt s ut xl) ll fi. .tolea Ed lt -tJo lso.l q .!o,. rl.
rrbd!r.lb.
ShlohrE lrt Cdt d? Th. nod Gdon 'tqd,i ltt!.ppt,6 udar
SAIT LAXE CITY, UTAH 84116-0690
wbn To }{dtty? l. O6art d l,rd.rltfllaabr{a Eb h l,r.. t di.l ltrt.
faan nllr oljt ol oi-.ro't arE trlt ry i,lrr4.'t*ldt lYltl{rgurd' nult rll,ty
by fav !. tg, Z a)t.n .! rl! bdno uthrEqrd tlotelr]rl(tEDqt. dl.r lhy
f: t 00e. rnm rDdt rfiir 30 d.yt ol lrhgine t!t nk inDt*a ttr SEl.
riqr'.a ioifi..do.'t a l,l, sn rirfitrr D llllt l.rd lnh.tn litnSt !.c.rc,
h trd.lt .
t.lritc Atw ds llo !E ttfr, hlta ic idll,drt t .i.b ttfr.nt]
thn dr.r h. .rild 5 a clII r|.tu rn l. cc..d Slqm h. -.ll l.nr l,
rtrtctr ruttcati f na $ i d hrl' Ci hh. hh.ti.lk! b alt.nl!..L
I l xew reounr I a. uexoeo I c. ct osune
Plea!. @-c!-cd!Llil!E.ll llems cxc.pl 'rigntlt ra' h tedon V. Thb torm
must b. cfrCeled for .err| bcalion conlainhE und.,lllurd rb.agE tenkr. It
nor. than fiv-e (5) tar{6 arc otned st thb locafion, phoocopy the lolloriq
rheeE, md napb continu8lbn sh..B to lhe lom'
Hbdncatton for Undergroun lorage Tanks
-aF L..rr-
TYPE OF NONFICATIOI.I
No. ol tank el ladllly
D NUMBEH a
DATE BECETVED
STAIE USE OT{LY
A Dlta Enr.tid lnb ComP.Jt.t
B. Dele Entry Cleik lnlthh
c. orrl.rwlr conE.d b
Clrrty R.!porr!G. Comm.nt
)
[. LOCATON OF TA],|K(S)t owNERsHrP oF TANK(S)
t rr!t, h. !E ltlqtaE.qt o -- t c.glr. ltll-.lE a-irECrlilr la.a { t2X Lfr:'8.1 l}r|t
ft14
t5o
1t
bngitude-
A1
,a.nr (CcP.rlcr l*
-*4o-3
n Larludc
-
lt-lffi..Etna
*-fer. PO. ad.ra
Eri,,
0..tr - ldEt f irtE tI. El ,
Fdy
PagE I
_ No. ol conlhudon !h..t3 ! dr.d
INSTRUCTOIIS
GENERAL INFOHMATION
-3E-fi-
E Feosra eorrmmea tr
I StatcGoemmcal tr
E Lalcov.mmel
Tanlr an bcaad on hnd wihln !t't lrdlan
Be!.n dbn or on othcr ttJ3t brdr.
T8nI! rn own d by mtlv. Am.rLi
nstbn, ffi.. or lndutud.
Trib€ or Na on:
C,ommeltlsl tr
tr
Prit
V. TY?E OF FACL]TY
S.l.ct th. Approprld. F.cily Dccrlplbn
_Gar S:ldlon
_ P.d.um Distrihrror
-
AIr Tarl (Alrllne)
_ Aircrdt Orvner
_ Aub Deahnhip
_ RalLoed
_ Fdod - ilon-fil[bry
_ F.deral - Mll[ary
_ lrdustlel
-
Contracbr
VI. @T{TACT PERSON IN CHARGE OF TANIG
Job T e
(ot-7qov 3 7 6a-
Nama Add]€ss
, ?oou. l-a1n g-
I I
I
-I I
-|-.I
Rbk Retention Gm0p
An,lrtec
Suroly Eond
Lcner ol Cr.dlt
Srao Fun6
Tru$ Fund
ottnr lrahod Abwed Specty
I havr.mat th. finsrEial rGponsiblllty raqulrrmonB in@rdarE wid! 40 CFR Subpert H
Ch.d( AI fid Apply
l-- s.[ ln"rr",r".
[El Commercial lruurarEe
Vllt CERfiHCATION (R..d end lign dt.r compt thg atr lactirn!)
l.c.triry under p€nalty ol l8w thsa t hrw p.rlonslly crarnhed and am hmihr x,nh fi. Horm&n 3ubmit d la $b End tl rt dtedocument} end thal b.s€d on rw hquity ol th(,3. Ldlyirurb &nmedlstdy nspomible lor oh.ining th. inbmabn, I bclhvc trd trrdrniucd lnformadon b truc,accriaj. rird fieldc.' --- -'-'----
Nan. lnd otlicial tido of owncr
or ow'r.rt authorizsd rp'.3.ntdv. (Prhtl
'// e *,^-*Ll,/- ,
Dac Sln
s/rYr{t
ed
-EPlj[[{:"glF.rePo]rjngtud.n lortib torrn b w.qc 30 mhrlles p.r,r.!pon . indding tim. b, roicuing hstrrdbnq
lgn9_1!.!]$illng_$. qs{- 1t::g{.tnd_cotilpLfitg !r-l{ radcwirp the bm. Scod co,nm.-aB regsrdtne thb -burd.n .dim;!. b9lg, lllto$qEl.fotrcT Erancrr_ Pt+223. U.S. Envi'onmemd plgt cUon Ag.ncr, .tot U Snei, Wastringro 6,C, aOCO, mart(.O'Al.ndon oesk ofibet bt EPA'Thb btm .rn.rid! ti. Plevix,3 dif'cdb; bil a! Fffi.d h ao CFR pian 2go, lppe na'U t. F-vtus.ditoB d this nolili5tion bm msy b. ur.d whiL supfiies ltst.
P.0. 2
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_ Tntd<trg/frsnspon
_ t ttlle!
_ Rosidcfllhl
-
Ferm( other (Eptainl eh u rcc lt
Phom Numb.r (,ndud. Area Code)
VII. FINANCIAL RESPOT,ISIBILITY
I
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tY ,r 4/
=a
lx DEscRlPIl()N Of UNUEH(,}{9UNU D lvnA(lc I ,1i"r^- (v(,nrP€tl'
Tsnk lenlifEetion Numb€r Tank No.
-
Tank t{o. ^ - Tank }to.
-
Tank l{0.
-1. Slatur of Tank
(m.rt only on.) CurcnUY h t !.
TrmPorarlY Otl d thr
(E-a--rl
Pcmancn0y Oi c{ Ur
(Eaa--bll
Arnrndrnent cl ldottndbn
Z Dde ol lnstdlstion (moJyear)
3. Esimded Total Capacity (gdblr3)
4. lldodsl ol Constnrc{ion
(Ue* a[ tha appV)
AsphEI Cod.d or Berc Sl..l
Cdhodlcslly P,st cl.d S1.ol
Epory Coatad Steel
Compos[e (Ste.l with Fbeqless)
Fibeqlass Reintorcrd Plastii:
Uned lntetbr
Double Walled
Polyelhylene Tank Jsdet
Cottctate
Excavdion Uner
Unknown
other, Plets. sp.cily
Has tank b€en repail€d?
5. Pi.ino (Mat.rhl)
Ua* an dtra app*) Bar Sleel
Galvanized St el
Fb€q|ass Reirdorc d Plssdc
CoPe..
Cslhodi:ally PDl.ctod
Double Walled
S.cordary Cotti.hm.nl
Unkmwn
Oth.r, Ploas. lp.cny
o
-Ia
-__-_____-:-
6. PUne
(M8tt dl
Gvpe)$d tpply)
Stdbn: no Y8lv. d tink
StElbn: Ydv. d tank
Ptassuti
GravtrY Fred
Has piping baon rePalnd?
aTankfb.-...l|-
d
Tr
t-
r
r
t-_l--T-t-_
t--
-_
7uo
t-l
Plgo 3
/. SuDslarro Cumnuy or Lll'l sbrsd
h Gr€dsst Osantity by Volumc
Gasolin.\-
D1e3.l
GslotDl
Ketosane
Hedng Ol
Used Ofl
Ohcr, Plear pccty
V
Haraldour Suhnce
CERCLA umr end/or,
CAS numbor
Mbdure ol Sltaarceg
Please spciry
X TAilKS OUT OF USE. OR C}IANGE N SERVICE
1. CbEhg o[ Tar*
A. Esdmst.d da!. hn used
(mo.ldayryeEr)
B. E3tmae dde tank cbsed
(mo.,tsyryear)
C. TanI war trrnoned llom gmund
D. Trrd( wa! clo!.d h ground
E Tmk lllled wifi lncrt mabrhl
D.scrb.
F. Change in servbe
f_:l
2 Sb Ar.ssmcm Complet.d
Psga 4
Bru.rr ol e bak detea.d
t
r
It-
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t
f
xL cElt I lF luA I luia ur (.,{.)Mrl-lAl'tet (r.^.,ffr tt r tr rvn ALl. NEYI AnllJ unrrl l.rsv
?lni tdenrrcaion rumur Tank ltb. _Tank l{o. _Tank f,b. ^ -Tank tlo. _
A hstsller c.rtfled by tank end
ttirE manuldur.rs
B. Lr.lallcr c.rtfr.d or lbenrd by thr
lnpl.mcndng t.nc,
C. lnrtallstlon lnsp.ct d by a
'rglstetod
angin.cr
D. hltallalion lnsp*red and
appovd by implementlng ag.ncy
E. Manrracture/s innalEllon cfi€cl-
lists hava b€en complsted
F. Am$er mcthod allowed by Stalc
agerrl. Please speity.
l. hdsldion
PIPING PIPINGTANKPIPIT{G TANK PIPING TANK PIPING
A Manualtank gaugirE
B. Tank tightn6$ tesling
C. lnventory cofilrols
D. Automatic lank gauging
E Vapor monitoring
F. Groundwat.r monitoring
G. lnt.rstttial monitoringdoublo walled
lankpiping
H. lntsrstitial moniloringlsecondary
containment
l. Aubmatic linc leak det cbr3
J. Une tightness t.sting
K Oth€r mothod albwed by
lmplementing Agancl. Plear
spcity.
3. Sprll and Overlill Prciectbn
A. Overlifl devb. installed
B. grll d.vic. hlrdbd
OATH: I cadify the inlormaiion conc.ming hrt lldim ra b p.ov,ld.d in r.don Xl b !u. b lh. b.d o, my b.lld rrd k E$l.dg..
Dd.am9 Signdlur.
P€itbn Compafly
hstaller:
Plg. 5
Tenk l'o.
-
TAI{K
EtIEEEEE
E
E
E
E
E
tl
EEE
tlEE
E
EEtl
Etltl
E
flEE
TANK
EEtl
t_lEEE
E
E
E
Z Rel€ase Det.ction (Mark ell that ryply)
r_l
t1
L]tt
ll tl
Itltl
L]
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L___l
il
flr
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tt t