DERR-2024-006327

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Utah DEQ Underground Storage Tank
State Use Onlv
lnstallation Notification Form
www.deq.utah.gov
Permit Required? E
Permit * 478-2024-2
Base Fee S 500
lnspectionFee*5200x I S roo
PST lnstall Fee 5200 x I S 600
Total ,S tzoo
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Certified lnstallers/Technicians on proiect
Name Trent DaltOn cert. #rL 0299 Exp. Date 08/01 12025
Name Corey Vincent Cert. # TL 0394 Exp. Date 08/01 12025
Name Randy Mickelsen Cert. # TL 0108 Exp. Date 0810112025
rank owner:Tenible Herbst Oil Company
Address:3340 W. Russell Road, Las Vegas, Utah 89118
Contact Name: Ben SCOtt Phone# [phone]
Facility Name:Terrible Herbst # 401
FacilityAddress:672E. Canyon Ranch Dr.,Cedar City, Utah 84720
lnstallatlon / Upgrade /Repair lnformation I Est. date work will commence:
Tank #1 212a 3l2b 4
Capacity 20,000 12,000 8,000 6,000
Tank Material dw Frp dw Frp dw Frp Frp
Piping Material dw plastic dw plastic dw plastic dw plastic
Substance stored Unleaded Premium Diesel Def
Check if uperade or repair only.| (Describe details below)
Describe Detaits of tnstalt/Upgrade/Repair ln the box below (Submit a drawing/site map of work to be done)
lnstall (1) 20k unleaded tank DW. nYzU$k solit Premium/Diesel tank D\{ and 11) 6k Def Tank
!nstall 6 Multi product Dispensers with UDC's and DW Plasitic product lines
lnstall Vebder Root 450+ tank monitor. lntall l-lapper Drop luDe aS over illl Oevlces ano opw splll
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Mail completed form to:
DEO/DERR
Box 144840
Salt Lake City, Utah 841L4-484O
195 N. 1950 W. 1* Floor
Salt Lake City, Utah
Phone [phone]
Fax (801.) 359-8853
UrAi.l OePAnTHrNT 0f
ENVIRONHTNTAL OUAt.I'I'Y
ENVIRON]iiE NTAL N ESPON 5E
& REMEDIATION
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