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Home My WebLink AboutDERR-2024-004274EZY CHEK SYSTEMS TEST DATE PRODUCT LINE TESTER Testing Company Information DATA SHEET Name Address City Test Location Information Precision Testing Technologies, Inc. 2026 W. Elk Creek Crt. Bluffdale, UT Test Location Information Phone Name Address Technican Information City Name Phone Cert # 801-886-9224 Contact Applied Pressure #1 Product Type:#2 Product Type: TIME DATA -/+GPL RES GPH TIME DATA -/+GPL RES GPH 0 0.0037 0.0000 0.0000 0 0.0037 0.0000 0.0000 0.0037 0.00370.0037 0.0037 0.0037 0.0037 0.0037 0.0037 0.0037 0.0037 0.0037 0.0037 FINAL RESULT:FINAL RESULT: #3 Product Type:#4 Product Type: TIME DATA -/+GPL RES GPH TIME DATA -/+GPL RES GPH 0 0.0037 0.0000 0.0000 0 0.0037 0.0000 0.0000 0.0037 0.0037 0.0037 0.0037 0.0037 0.0037 0.0037 0.00370.0037 0.0037 0.0037 0.0037 FINAL RESULT:FINAL RESULT: #5 Product Type:#6 Product Type: TIME DATA -/+GPL RES GPH TIME DATA -/+GPL RES GPH 0 0.0037 0.0000 0.0000 0 0.0037 0.0000 0.000000.0037 0.0000 0.0000 0 0.0037 0.0000 0.0000 0.0037 0.0037 0.0037 0.0037 0.0037 0.0037 0.0037 0.0037 0.0037 0.0037 FINAL RESULT:FINAL RESULT: Facility ID# : 02/12/2024 5000401 Harts Gas & Food #30 135 S. Main Huntington, UT 84528 Dominic Salas UT-378 55psi Dsl 0 78 15 77 -1 .0037 .0148 30 77 0 0 0 Pass Dye Dsl 0 73 15 72 -1 .0037 .0148 30 72 0 0 0 Pass Reg 0 68 15 68 0 0 0 30 68 0 0 0 Pass Prm 0 63 15 57 -6 .0222 .0888 30 52 -6 .0222 .0888 Incon 02/12/2024 Dominic Salas UT-378 pei.org 49 Recommended Practices for the Testing and Verification of Spill, Overfill, Leak Detection and Secondary Containment Equipment at UST Facilities APPENDIX C-9 MECHANICAL AND ELECTRONIC LINE LEAK DETECTORS PERFORMANCE TEST )DFLOLW\1DPH2ZQHU $GGUHVV$GGUHVV &LW\6WDWH=LS&RGH&LW\6WDWH=LS&RGH )DFLOLW\,'3KRQH 7HVWLQJ&RPSDQ\3KRQH'DWH 7KLVGDWDVKHHWFDQEHXVHGWRWHVWPHFKDQLFDOOLQHOHDNGHWHFWRUV0//'DQGHOHFWURQLFOLQHOHDNGHWHFWRUV(//'ZLWKVXEPHUVLEOH WXUELQHSXPS673V\VWHPV6HH3(,536HFWLRQVDQGIRUWHVWSURFHGXUHV /LQH1XPEHU 3URGXFW6WRUHG /HDN'HWHFWRU0DQXIDFWXUHU /HDN'HWHFWRU0RGHO 7\SHRI/HDN'HWHFWRU 0//' (//' 0//' (//' 0//' (//' 0//' (//' 0//' (//' 0//' (//' MLLD (ALL PRESSURE MEASUREMENTS ARE MADE IN PSIG) 673)XOO2SHUDWLQJ3UHVVXUH &KHFN9DOYH+ROGLQJ3UHVVXUH /LQH5HVLOLHQF\POOLQHEOHHGEDFNYRO XPHDVPHDVXUHGIURPFKHFNYDOYHKROG LQJSUHVVXUHWR]HURSVLJ 6WHS7KURXJK7LPHLQ6HFRQGVWLPHWKH 0//'KHVLWDWHVDWPHWHULQJSUHVVXUH EHIRUHJRLQJWRIXOORSHUDWLQJSUHVVXUH DVPHDVXUHGIURPSVLJZLWKQROHDN LQGXFHGRQWKHOLQH 0HWHULQJ3UHVVXUH673SUHVVXUHZKHQ VLPXODWHGOHDNUDWHJSKDWSVLJ 2SHQLQJ7LPHLQ6HFRQGVWKHWLPHWKH 0//'RSHQVWRDOORZIXOOSUHVVXUHDIWHU VLPXODWHGOHDNLVVWRSSHG 'RHVWKH673SUHVVXUHUHPDLQDWRU EHORZWKHPHWHULQJSUHVVXUHIRUDWOHDVW VHFRQGVZKHQWKHVLPXODWHGOHDNLV LQGXFHG" <HV1R<HV1R <HV1R <HV1R <HV1R <HV1R 'RHVWKHOHDNGHWHFWRUUHVHWWULSZKHQ WKHOLQHSUHVVXUHLVEOHGRIIWR]HURSVLJ"<HV1R <HV1R <HV1R <HV1R <HV1R <HV1R 'RHVWKH673SURSHUO\F\FOHRQRIIXQGHU QRUPDOIXHOV\VWHPRSHUDWLRQFRQGLWLRQV"<HV1R <HV1R <HV1R <HV1R <HV1R <HV1R $´1RµDQVZHUWRHLWKHURIWKHDERYHTXHVWLRQVLQGLFDWHVWKH0//'IDLOVWKHWHVW ELLD (ALL PRESSURE MEASUREMENTS ARE MADE IN PSIG) 673)XOO2SHUDWLQJ3UHVVXUH +RZPDQ\WHVWF\FOHVDUHREVHUYHG EHIRUHDODUPVKXWGRZQRFFXUV" 'RHVWKHVLPXODWHGOHDNFDXVHDQDODUP"<HV1R <HV1R <HV1R <HV1R <HV1R <HV1R $´1RµDQVZHUWRWKHDERYHTXHVWLRQLQGL FDWHVWKH(//'IDLOVWKHWHVW 'RHVWKHVLPXODWHGOHDNFDXVHDQ673 VKXWGRZQ" <HV1R 1$ <HV1R 1$ <HV1R 1$ <HV1R 1$ <HV1R 1$ <HV1R 1$ Test Results 3DVV)DLO 3DVV)DLO 3DVV)DLO 3DVV)DLO 3DVV)DLO 3DVV)DLO Comments: 7HVWHU·V1DPH BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB 7HVWHU·V6LJQDWXUHBBBBBBBBBBBBBBBBBBBBBBBBBBBBB Precision Testing Technologies Inc.801-886-9224 Harts Gas & Food #30 135 S. Main Huntington, UT84528 5000401 Harts Gas & Food LLC PO BOX 418 American Fork, UT 84003 02/12/2024 1 Dsl VR FX1DV 4 34 17 150 1 10 5 4 4 4 4 2 Dye Dsl VR FX1DV 4 30 18 150 1 9 4 4 4 4 4 3 Reg VR FX1V 4 31 17 250 1 10 5 4 4 4 4 4 Prm VR FX1V 4 29 15 250 1 10 3 4 4 4 4 Dominic Salas UT-378 pei.org 43 Recommended Practices for the Testing and Verification of Spill, Overfill, Leak Detection and Secondary Containment Equipment at UST Facilities APPENDIX C-3 SPILL BUCKET INTEGRITY TESTING HYDROSTATIC TEST METHOD SINGLE AND DOUBLE-WALLED VACUUM TEST METHOD )DFLOLW\1DPH2ZQHU $GGUHVV$GGUHVV &LW\6WDWH=LS&RGH&LW\6WDWH=LS&RGH )DFLOLW\,'3KRQH 7HVWLQJ&RPSDQ\3KRQH'DWH 7KLVSURFHGXUHLVWRWHVWWKHOHDNLQWHJULW\RIVLQJOHDQGGRXEOHZDOOHGVSLOOEXFNHWV6HH3(,536HFWLRQIRUK\GURVWDWLF WHVWPHWKRG6HFWLRQIRUVLQJOHZDOOHGYDFXXPWHVWPHWKRGDQG6HFWLRQIRUGRXEOHZDOOHGYDFXXPWHVWPHWKRG 7DQN1XPEHU 3URGXFW6WRUHG 6SLOO%XFNHW &DSDFLW\ 0DQXIDFWXUHU &RQVWUXFWLRQ6LQJOHZDOOHG 'RXEOHZDOOHG 6LQJOHZDOOHG 'RXEOHZDOOHG 6LQJOHZDOOHG 'RXEOHZDOOHG 6LQJOHZDOOHG 'RXEOHZDOOHG 6LQJOHZDOOHG 'RXEOHZDOOHG 6LQJOHZDOOHG 'RXEOHZDOOHG 7HVW7\SH +\GURVWDWLF 9DFXXP 6LQJOHZDOOHG 'RXEOHZDOOHG +\GURVWDWLF 9DFXXP 6LQJOHZDOOHG 'RXEOHZDOOHG +\GURVWDWLF 9DFXXP 6LQJOHZDOOHG 'RXEOHZDOOHG +\GURVWDWLF 9DFXXP 6LQJOHZDOOHG 'RXEOHZDOOHG +\GURVWDWLF 9DFXXP 6LQJOHZDOOHG 'RXEOHZDOOHG +\GURVWDWLF 9DFXXP 6LQJOHZDOOHG 'RXEOHZDOOHG 6SLOO%XFNHW7\SH 3URGXFW 9DSRU 3URGXFW 9DSRU 3URGXFW 9DSRU 3URGXFW 9DSRU 3URGXFW 9DSRU 3URGXFW 9DSRU /LTXLGDQGGHEULV UHPRYHGIURP VSLOOEXFNHW" <HV1R <HV1R <HV1R <HV1R <HV1R <HV1R 9LVXDO,QVSHFWLRQ 1RFUDFNVORRVH SDUWVRUVHSDUD WLRQRIWKHEXFNHW IURPWKHILOOSLSH 3DVV)DLO 3DVV)DLO 3DVV)DLO 3DVV)DLO 3DVV)DLO 3DVV)DLO 7DQNULVHUFDS LQFOXGHGLQWHVW" <HV1R 1$ <HV1R 1$ <HV1R 1$ <HV1R 1$ <HV1R 1$ <HV1R 1$ ,VGUDLQYDOYH LQFOXGHGLQWHVW" <HV1R 1$ <HV1R 1$ <HV1R 1$ <HV1R 1$ <HV1R 1$ <HV1R 1$ 6WDUWLQJ/HYHO 7HVW6WDUW7LPH (QGLQJ/HYHO 7HVW(QG7LPH 7HVW3HULRG /HYHO&KDQJH 3DVVIDLOFULWHULD0XVWSDVVYLVXDOLQVSHFWLRQ+\GURVWDWLF:DWHUOHYHOGURSRIOHVVWKDQLQFK9DFXXPVLQJOHZDOOHGRQO\ 0DLQWDLQDWOHDVWLQFKHVZDWHUFROXPQ9DFXXPGRXEOHZDOOHGPDLQWDLQDWOHDVWLQFKHVZDWHUFROXPQ Test Results 3DVV)DLO 3DVV)DLO 3DVV)DLO 3DVV)DLO 3DVV)DLO 3DVV)DLO Comments: $OOOLTXLGVDQGGHEULVPXVWEHGLVSRVHGRISURSHUO\ 7HVWHU·V1DPHBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB 7HVWHU·V6LJQDWXUHBBBBBBBBBBBBBBBBBBBBBBBBBBBBB Precision Testing Technologies Inc.801-886-9224 Harts #30 5000401 02/12/2024 1 Dsl 5gal Opw 4 4 4 4 4 4 4 11" 0min 11" 60min 1hr 0" 4 2 Dye Dsl 5gal Opw 4 4 4 4 4 4 4 11.25" 0min 11.25" 60min 1hr 0" 4 3 Reg 5gal Opw 4 4 4 4 4 4 4 10.75" 0min 10.75" 60min 1hr 0" 4 4 Prm 5gal Opw 4 4 4 4 4 4 4 10.75" 0min 10.75" 60min 1hr 0" 4 Dominic Salas UT-378 pei.org 47 Recommended Practices for the Testing and Verification of Spill, Overfill, Leak Detection and Secondary Containment Equipment at UST Facilities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´1RµWKHV\VWHPKDVIDLOHGWKHWHVW Test Results 3DVV)DLO 3DVV)DLO 3DVV)DLO 3DVV)DLO Comments: 7HVWHU·V1DPHBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB 7HVWHU·V6LJQDWXUHBBBBBBBBBBBBBBBBBBBBBBBBBBBBB Precision Testing Technologies Inc.801-886-9224 Harts Gas & Food #30 5000401 1 Dsl VR TLS-350 11627 92" 4 4 4 4 75 7/8" 4 1.5" 4 4 2 Dye Dsl VR TLS-350 11627 92" 4 4 4 4 75 7/8" 4 1.5" 4 4 3 Reg VR TLS-350 11627 92" 4 4 4 4 75 7/8" 4 1" 4 4 4 Prm VR TLS-350 9728 92" 4 4 4 4 75 3/4" 4 1" 4 4 Dominic Salas UT-378 02/12/2024 PE I / R P 1 2 0 0 - 1 2 pe i . o r g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´1RµDQVZHUVLQGLFDWHVWKHVHQVRUIDLOVWKHWHVW Test Results 3DVV)DLO 3DVV)DLO 3DVV)DLO 3DVV)DLO 3DVV)DLO 3DVV)DLO 3DVV)DLO Comments: 7HVWHU·V1DPHBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB 7HVWHU·V6LJQDWXUHBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB Precision Testing Technologies Inc.801-886-9224 Harts Gas & Food #30 5000401 02/12/2024 Disp 1,2 Lines 4 4 4 4 4 4 4 4 3,4 Lines 4 4 4 4 4 4 4 4 5,6 Lines 4 4 4 4 4 4 4 4 7,8 Lines 4 4 4 4 4 4 4 4 Dominic Salas UT-378 Pressure/Vacuum (P/V) Vent Valve Data Sheet Facility Name: Test Date: Address: Test Company: Precision Testing Technologies City: Tester Name: Product: P/V Valve Manufacturer: Model Number: Pass Fail Manufacturers Specified Positive Leak Rate (CFH): Manufacturers Specified Negative Leak Rate (CFH): Measured Positive Leak Rate (CFH): Measured Negative Leak Rate (CFH): Positive Cracking Pressure (in H2O): Negative Cracking Pressure (in H2O): Product: P/V Valve Manufacturer: Model Number: Pass Fail Manufacturers Specified Positive Leak Rate (CFH): Manufacturers Specified Negative Leak Rate (CFH): Measured Positive Leak Rate (CFH): Measured Negative Leak Rate (CFH): Positive Cracking Pressure (in H2O): Negative Cracking Pressure (in H2O): Product: P/V Valve Manufacturer: Model Number: Pass Fail Manufacturers Specified Positive Leak Rate (CFH): Manufacturers Specified Negative Leak Rate (CFH): Measured Positive Leak Rate (CFH): Measured Negative Leak Rate (CFH): Positive Cracking Pressure (in H2O): Negative Cracking Pressure (in H2O): Product: P/V Valve Manufacturer: Model Number: Pass Fail Manufacturers Specified Positive Leak Rate (CFH): Manufacturers Specified Negative Leak Rate (CFH): Measured Positive Leak Rate (CFH): Measured Negative Leak Rate (CFH): Positive Cracking Pressure (in H2O): Negative Cracking Pressure (in H2O): 2.5" to 6" wc <=0.05 cfh @ 2" wc 2.5" to 6" wc <=0.05 cfh @2" wc 2.5" to 6" wc <=0.05 cfh 2" wc 2.5" to 6" wc <=0.05 cfh 2" wc 6" to 10" wc <=0.21 cfh @ 4" wc 6" to 10" wc <=0.21 cfh @ 4" wc 6" to 10" wc <=0.21 cfh @ 4" wc 6" to 10" wc <=0.21 cfh @ 4" wc Harts #30 135 S. Main Huntington 02/12/2024 Dominic Salas Reg OPW 623V 4 .02 2.78 .16 6.64 Prm OPW 623V 4 .03 3.45 .16 6.99 Harts #30 135 S. Main Dominic Salas 02/12/2024 Huntington 1 of 3 parkland fueling equipment worksheet 022023 Fueling Equipment Worksheet Store # / Name: _________________________ Address:__________________________________ ***** FUEL TANKS Product: If Other, list Product: AST / UST Tank Type (ACT 100, FRP, Steel, STI-3) Tank Material? Double Wall? ( Y / N ) Capacity Gallons (per chart if available): Tank Chart available? Diameter Inches (measured): Length Inches (per chart): Drop tube present? # Of inches Drop Tube of bottom. Stage I VR Type (Coaxial, 2-pt) Swivel Type Stage I Adaptor ( Y / N) Vapor Bucket type (SW / DW / Manway? Tank #: Tank #: Tank #: Tank #: Tank #: Tank #: U UL+ S D Other U UL+ S D Other U UL+ S D Other U UL+ S D Other U UL+ S D Other U UL+ S D Other Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N SW / DW / M SW / DW / M SW / DW / M SW / DW / M SW / DW / M SW / DW / M Overfill Protection Present / Not Present ( P / NP ) Ball Float (BF), Drop Tube Valve (DTV) BF & Ex Alarm (BFE) ; Ex. Alarm (EA) P / NP P / NP P / NP P / NP P / NP P / NP Overspill Containment Catchment Basin, Multi-Port w/ bucket Spill Bucket Single or Double wall? Model / Manufacturer: Overspill Condition ( G / B )? Drain Valve Functional? Spill Bucket Size? CB / MP CB / MP CB / MP CB / MP CB / MP CB / MP S / D S / D S / D S / D S / D S / D G / B G / B G / B G / B G / B G / B Y / N Y / N Y / N Y / N Y / N Y / N Fill Riser Adaptor? (Locking, Stationary, Swivel) L / ST / SW L / ST / SW L / ST / SW L / ST / SW L / ST / SW L / ST / SW ESO Button(s) Operational? Y / N Y / N Y / N Y / N Y / N Y / N Location of ESO (s) ***** FUEL SUB-PUMPS Sub-Pump (STP) No: Tank #: Product: U UL+ S D Other U UL+ S D Other U UL+ S D Other U UL+ S D Other U UL+ S D Other U UL+ S D Other 1 2 3 4 DYED UST UST UST UST FRP FRP FRP FRP FRP FRP FRP FRP 11627 11627 11627 20168 92 92 92 5GAL 5GAL 5GAL 5GAL 1 2 3 4 1 DSL 2 DYED DSL Hart's #30 135 S Main Huntington UT 92 OPW OPW OPW OPW 3 REGULAR 4 PREM 2 of 3 parkland fueling equipment worksheet 022023 FUEL SUB-PUMPS (Cont.) If Other, list Product: Leak Detector Type: E / M E / M E / M E / M E / M E / M Manufacturer? Serial Number: Type: FX, PLD, FE, Etc. Sub Pump Sump/Liner Type: (Sump/Liner/None) Sump Condition (Good / Bad) Turbine Pump (STP) Horsepower? Beaudreau Sensors present? ( Y / N ) Positioned on bottom? ( Y / N ) ATG Sensors present? ( Y / N ) Positioned on bottom? ( Y / N ) S / L / None S / L / None S / L / None S / L / None S / L / None S / L / None G / B G / B G / B G / B G / B G / B Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N ***** FUEL DISPENSERS Number of Hoses: Condition of Hoses (G / B)? Dispenser Model: Type Code: (Single, Dual, Multi.) Manufacturer? Blender Installed? Blender = Mechanical / Electronic? Blend Ratio? Are Shear Valves anchored? Shear Valve Operational? Disp. #: Disp. #: Disp. #: Disp. #: Disp. #: Disp. #: G / B G / B G / B G / B G / B G / B S / D / M S / D / M S / D / M S / D / M S / D / M S / D / M Y / N Y / N Y / N Y / N Y / N Y / N M / E M / E M / E M / E M / E M / E Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Disp. Flex Hose (Present? Y/N) Disp. Flex Hose Booted/CP/Cont.? Y / N Y / N Y / N Y / N Y / N Y / N B / CP / Cont. B / CP / Cont. B / CP / Cont. B / CP / Cont. B / CP / Cont. B / CP / Cont. Flex Hose or Swing Joint? F / S F / S F / S F / S F / S F / S DWFRP Boots Connected or Open? C / O C / O C / O C / O C / O C / O Dispenser Sump/Liner Type:(Sump/Liner/None) Sump Condition (G / B) Beaudreau Sensors present ? ( Y / N ) Positioned on bottom? ( Y / N ) ATG Sensors Present? ( Y / N ) Positioned on bottom? ( Y / N ) S / L / None S / L / None S / L / None S / L / None S / L / None S / L / None G / B G / B G / B G / B G / B G / B Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N VR VR VR VR PLLD PLLD PLLD PLLD 1/2 3/4 5/6 7/8 11/12 3 of 3 parkland fueling equipment worksheet 022023 Additional Comments: Company:_______________________________________ Representative:___________________________________ Date:___________________________________________ ***** FUEL LINES Product: If Other, list Product: Type: DWFRP, FRP, Steel, Unknown) Type (Enviroflex, Flexworks, Etc.)? Manufacturer ? STP Flex Hose present? STP Flex Hose Booted /CP/ Cont.? Tank #: Tank #: Tank #: Tank #: Tank #: Tank #: U UL+ S D Other U UL+ S D Other U UL+ S D Other U UL+ S D Other U UL+ S D Other U UL+ S D Other Y / N Y / N Y / N Y / N Y / N Y / N B / CP / Cont. B / CP / Cont. B / CP / Cont. B / CP / Cont. B / CP / Cont. B / CP / Cont. Sub Pump Connection: (Flex Hose, Swing Joint, Unknown) DWFRP Boots Connected or Open? F / S / U F / S / U F / S / U F / S / U F / S / U F / S / U C / O C / O C / O C / O C / O C / O ***** VENTS Product: Product: Location: C=Canopy; L=Lot; B=Building Manifolded Aboveground? ( Y / N ) Pressure/Vacuum Cap Type? U UL+ S D Other U UL+ S D Other U UL+ S D Other U UL+ S D Other U UL+ S D Other U UL+ S D Other C / L / B C / L / B C / L / B C / L / B C / L / B C / L / B Y / N Y / N Y / N Y / N Y / N Y / N ***** CATHODIC PROTECTION Impressed Current System: (Y / N) Rectifier Location ? Rectifier Log on Site ? Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N ***** AUTOMATIC TANK GAUGE Model? Comments: Software Version No? Is Software up to date? Y / N ***** RELEASE DETECTION METHOD Tank Primary Release Detection: Comments: Tank Secondary Release Detection: Piping Primary Release Detection: Piping Secondary Release Detection: **** OPERATIONAL CHECKS Gasoline/Compliance Binder Present? Y / N Last Test Dates? 30-Day Inspections completed by: UST Permit / Delivery Certificate Present (onsite) and Current? Y / N Emergency Response Plan Posted? Y / N SPCC Available (if required) Y / N DWFRP DWFRP DWFRP DWFRP 1 2 3 4 VR TLS 350 Precision Testing Technologies, Inc. Dominic Salas UT0378 2/12/2024