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Testing and Inspection Certificate Tanknology Inc. 11000 North MoPac Expressway, Suite 500, Austin, TX 78759 800-800-4633 www.tanknology.com Page 1 of 1 Test Date 2/9/2024 Tanknology WO#NW1-2364471 Test Purpose POST CONST Customer PO#38390783 Customer Location SAM'S CLUB 2001 S.E. 10TH STREET DEPT. # 449562 BENTONVILLE, AR 72716 WALMART #WM4696 1274 S US 189 BLVD B HEBER CITY, UT 84032 Attn: PROJECT MANAGER Attn: Asset Protection Manager (479) 204-3407 () Test / Inspection Description Item Tested Date Tested Result ATG Certification 2/9/2024 P E-Stop 2/9/2024 P Impact Valve 2/9/2024 P Leak Detector Test 1 2/9/2024 P Leak Detector Test 2 2/9/2024 P Leak Detector Test 3 2/9/2024 P Leak Detector Test 4 2/9/2024 P Line Tightness Test 1 2/9/2024 P Line Tightness Test 2 2/9/2024 P Line Tightness Test 3 2/9/2024 P Line Tightness Test 4 2/9/2024 P Overfill Survey 2/9/2024 P Pressure Vent Cap 2/9/2024 P Spill Bucket Leak Test 1 2/9/2024 P Spill Bucket Leak Test 2 2/9/2024 P Spill Bucket Leak Test 3 2/9/2024 P Spill Bucket Leak Test 4 2/9/2024 P Stage I Pressure Decay 1 2/9/2024 P Stage I Pressure Decay 2 2/9/2024 P Stage I Pressure Decay 3 2/9/2024 P Tank Interstitial 1 2/9/2024 P Tank Interstitial 2 2/9/2024 P Tank Interstitial 3 2/9/2024 P Tank Interstitial 4 2/9/2024 P Tank Tightness Test 1 2/9/2024 P Tank Tightness Test 2 2/9/2024 P Tank Tightness Test 3 2/9/2024 P Tank Tightness Test 4 2/9/2024 P Tanknology Representative: David Edens Technician: Non Tech WO Telephone: ()Technician Certification: (See forms) Tanknology EZY 3 LOCATOR PLUS Manufactured by ESTABROOKS, INC 877-368-7215 TEST DATE Location TANK # TIGHT TANK THIS UNDERGROUND STORAGE TANK PASSES THE CRITERIA SET FORTH BY THE U.S. EPA. ULLAGE (DRY) PORTION OF LEAK THIS UNDERGROUND STORAGE TANK FAILS THE CRITERIA SET FORTH BY THE U.S. EPA. FINAL REPORT STATE FACILITY ID# PRODUCT TYPE ULLAGE VOL. PRODUCT VOL. TOTAL TANK VOL. THE ACOUSTIC CHARACTERISTIC OF A LEAK REVEALS: BELOW PRODUCT LEVEL (WET) PORTION LEAK THIS UNDERGROUND STORAGE TANK FAILS THE CRITERIA SET FORTH BY THE U.S. EPA. Print Name Testing Firm Address Certification # Expiration Date: Telephone #801-886-9224 Operator Information No Water Intrusion Water Instrusion Not Applicable WATER SENSOR INDICATES: (CHECK ONLY ONE) Precision Testing Tech, Inc. 2026 Elk Creek Crt. Bluffdale, UT Walmart Supercenter #4696 1274 S. U.S. Hwy. 189 Heber City, UT 84032 02/09/2024 19,782 15,109 4,673 REG 1100388 1 4 4 Max LaRou EST-26-6267 05-19-24 EZY 3 LOCATOR PLUS Manufactured by ESTABROOKS, INC 877-368-7215 TEST DATE Location TANK # TIGHT TANK THIS UNDERGROUND STORAGE TANK PASSES THE CRITERIA SET FORTH BY THE U.S. EPA. ULLAGE (DRY) PORTION OF LEAK THIS UNDERGROUND STORAGE TANK FAILS THE CRITERIA SET FORTH BY THE U.S. EPA. FINAL REPORT STATE FACILITY ID# PRODUCT TYPE ULLAGE VOL. PRODUCT VOL. TOTAL TANK VOL. THE ACOUSTIC CHARACTERISTIC OF A LEAK REVEALS: BELOW PRODUCT LEVEL (WET) PORTION LEAK THIS UNDERGROUND STORAGE TANK FAILS THE CRITERIA SET FORTH BY THE U.S. EPA. Print Name Testing Firm Address Certification # Expiration Date: Telephone #801-886-9224 Operator Information No Water Intrusion Water Instrusion Not Applicable WATER SENSOR INDICATES: (CHECK ONLY ONE) Precision Testing Tech, Inc. 2026 Elk Creek Crt. Bluffdale, UT Walmart Supercenter #4696 1274 S. U.S. Hwy. 189 Heber City, UT 84032 02/09/2024 11,904 9,156 2,748 REG 1100388 2 4 4 Max LaRou EST-26-6267 05-19-24 EZY 3 LOCATOR PLUS Manufactured by ESTABROOKS, INC 877-368-7215 TEST DATE Location TANK # TIGHT TANK THIS UNDERGROUND STORAGE TANK PASSES THE CRITERIA SET FORTH BY THE U.S. EPA. ULLAGE (DRY) PORTION OF LEAK THIS UNDERGROUND STORAGE TANK FAILS THE CRITERIA SET FORTH BY THE U.S. EPA. FINAL REPORT STATE FACILITY ID# PRODUCT TYPE ULLAGE VOL. PRODUCT VOL. TOTAL TANK VOL. THE ACOUSTIC CHARACTERISTIC OF A LEAK REVEALS: BELOW PRODUCT LEVEL (WET) PORTION LEAK THIS UNDERGROUND STORAGE TANK FAILS THE CRITERIA SET FORTH BY THE U.S. EPA. Print Name Testing Firm Address Certification # Expiration Date: Telephone #801-886-9224 Operator Information No Water Intrusion Water Instrusion Not Applicable WATER SENSOR INDICATES: (CHECK ONLY ONE) Precision Testing Tech, Inc. 2026 Elk Creek Crt. Bluffdale, UT Walmart Supercenter #4696 1274 S. US. Hwy. 189 Heber City, UT 84032 02/09/2024 7,901 5,508 2,393 PRM 1100388 3 4 4 Max LaRou EST-26-6267 05-19-24 EZY 3 LOCATOR PLUS Manufactured by ESTABROOKS, INC 877-368-7215 TEST DATE Location TANK # TIGHT TANK THIS UNDERGROUND STORAGE TANK PASSES THE CRITERIA SET FORTH BY THE U.S. EPA. ULLAGE (DRY) PORTION OF LEAK THIS UNDERGROUND STORAGE TANK FAILS THE CRITERIA SET FORTH BY THE U.S. EPA. FINAL REPORT STATE FACILITY ID# PRODUCT TYPE ULLAGE VOL. PRODUCT VOL. TOTAL TANK VOL. THE ACOUSTIC CHARACTERISTIC OF A LEAK REVEALS: BELOW PRODUCT LEVEL (WET) PORTION LEAK THIS UNDERGROUND STORAGE TANK FAILS THE CRITERIA SET FORTH BY THE U.S. EPA. Print Name Testing Firm Address Certification # Expiration Date: Telephone #801-886-9224 Operator Information No Water Intrusion Water Instrusion Not Applicable WATER SENSOR INDICATES: (CHECK ONLY ONE) Precision Testing Tech, Inc. 2026 Elk Creek Crt. Bluffdale, UT Walmart Supercenter #4696 1274 S. U.S. Hwy. 189 Heber City, UT 84032 02/09/2024 19,782 5,382 14,400 DSL 1100388 4 4 4 Max LaRou EST-26-6267 05-19-24 EZY 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# : 02/09/2024 1100388 Walmart Supercenter #4696 1274 S. Hwy. 189 Heber, UT 84032 435-709-3015 Alec Rapoza Max LaRou UT-412 65 P.S.I. REG 1 0 74 15 74 0 0 0 30 74 0 0 0 PASS REG 2 0 61 15 61 0 0 0 30 61 0 0 0 PASS PRM 0 53 15 53 0 0 0 30 53 0 0 0 PASS DSL 1 0 39 15 37.5 -1.5 0.0055 0.0222 30 36 -1.5 0.0055 0.0222 PASS DSL 2 0 27 15 27 0 0 0 30 27 0 0 0 PASS 02/09/2024 Max LaRou UT-412 ;,~'\)~ I I ~ms & Tra ining for the l _1:i Petroleum Industry I 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\1DPH 2ZQHU $GGUHVV $GGUHVV &LW\6WDWH=LS&RGH &LW\6WDWH=LS&RGH )DFLOLW\,' 3KRQH 7HVWLQJ&RPSDQ\ 3KRQH 'DWH 7KLVGDWDVKHHWFDQEHXVHGWRWHVWPHFKDQLFDOOLQHOHDNGHWHFWRUV 0//' DQGHOHFWURQLFOLQHOHDNGHWHFWRUV (//' ZLWKVXEPHUVLEOH WXUELQHSXPS 673 V\VWHPV6HH3(,536HFWLRQV DQG IRUWHVWSURFHGXUHV /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\ PO OLQHEOHHGEDFNYRO XPHDVPHDVXUHGIURPFKHFNYDOYHKROG LQJSUHVVXUHWR]HURSVLJ 6WHS7KURXJK7LPHLQ6HFRQGV WLPHWKH 0//'KHVLWDWHVDWPHWHULQJSUHVVXUH EHIRUHJRLQJWRIXOORSHUDWLQJSUHVVXUH DVPHDVXUHGIURPSVLJZLWKQROHDN LQGXFHGRQWKHOLQH 0HWHULQJ3UHVVXUH 673SUHVVXUHZKHQ VLPXODWHGOHDNUDWHJSKDWSVLJ 2SHQLQJ7LPHLQ6HFRQGV WKHWLPHWKH 0//'RSHQVWRDOORZIXOOSUHVVXUHDIWHU VLPXODWHGOHDNLVVWRSSHG 'RHVWKH673SUHVVXUHUHPDLQDWRU EHORZWKHPHWHULQJSUHVVXUHIRUDWOHDVW VHFRQGVZKHQWKHVLPXODWHGOHDNLV LQGXFHG" <HV1R<HV1R <HV1R <HV1R <HV1R <HV1R 'RHVWKHOHDNGHWHFWRUUHVHW WULS ZKHQ 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 Walmart Supercenter #4696 1274 S. U.S. HWY. 189 Heber, UT 84032 1100388 Walmart Inc. 2101 SE. Simple Savings Dr. Bentonville, AR 72716 435-709-3015 02/09/2024 1 REG V.R. PLLD 4 42 2 4 4 4 2 REG V.R. PLLD 4 39 2 4 4 4 3 PRM V.R. PLLD 4 38 2 4 4 4 4 DSL V.R. PLLD 4 43 2 4 4 4 5 DSL V.R. PLLD 4 40 2 4 4 Max LaRou UT-412 □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ pei.org 41 Recommended Practices for the Testing and Verification of Spill, Overfill, Leak Detection and Secondary Containment Equipment at UST Facilities APPENDIX C-1 7HVWHU·V1DPHBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB 7HVWHU·V6LJQDWXUHBBBBBBBBBBBBBBBBBBBBBBBBBBBBB TANK SECONDARY CONTAINMENT INTEGRITY TESTING DRY TEST METHOD )DFLOLW\1DPH 2ZQHU $GGUHVV $GGUHVV &LW\6WDWH=LS&RGH &LW\6WDWH=LS&RGH )DFLOLW\,' 3KRQH 7HVWLQJ&RPSDQ\ 3KRQH 'DWH 7KLVGDWDVKHHWLVIRUWHVWLQJWKHLQWHJULW\RIWKHGU\VHFRQGDU\FRQWDLQPHQWRID8676HH3(,536HFWLRQIRUWKHWHVW SURFHGXUH 7DQN1XPEHU 7DQN0DWHULDO 3URGXFW6WRUHG 7DQN&DSDFLW\ JDOORQV 7HVW6WDUW7LPH ,QLWLDO9DFXXP5HDGLQJ LQFKHV+J 6HH7DEOH EHORZ 6SHFLILHG7HVW'XUDWLRQ 6HH7DEOHEHORZ KRXU KRXUV KRXU KRXUV KRXU KRXUV KRXU KRXUV KRXU KRXUV KRXU KRXUV 7HVW(QG7LPH )LQDO9DFXXP5HDGLQJ LQFKHV+J ,VWKH$QQXODU6SDFH 'U\$IWHUWKH7HVW" <HV1R <HV1R <HV1R <HV1R <HV1R <HV1R 7HVW5HVXOWV 3DVV)DLO 3DVV)DLO 3DVV)DLO 3DVV)DLO 3DVV)DLO 3DVV)DLO TABLE 4-1. Test Parameters Tank Type Vacuum, inches Hg Capacity, gallons Duration, hours )LEHUJODVV 6WHHO 7RWDOWDQNFDSDFLW\LQFOXGLQJDOOFRPSDUWPHQWVLQDPXOWLFRPSDUWPHQWWDQN Comments: Precision Testing Technologies Inc (801) 886-9224 Walmart Supercenter #4696 1100388 02/09/2024 1 FRP REG 19,782 0 Min. -10"Hg 4 60 Min. -10"Hg 4 4 2/3 FRP REG2/PRM 19,805 0 Min. -10"Hg 4 60 Min. -10"Hg 4 4 4 FRP DSL 19,782 0 Min. -10"Hg 4 60 Min. -10"Hg 4 4 Max LaRou UT-412 □ □ [J □ □ □ [J □ □ [J □ □ [J □ □ □ [J □ [J [J □ □ □ □ [J [J □ □ □ □ [] □ □ [J □ □ 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\1DPH 2ZQHU $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 3DVVIDLOFULWHULD 0XVWSDVVYLVXDOLQVSHFWLRQ+\GURVWDWLF :DWHUOHYHOGURSRIOHVVWKDQLQFK 9DFXXPVLQJOHZDOOHGRQO\ 0DLQWDLQDWOHDVWLQFKHVZDWHUFROXPQ 9DFXXPGRXEOHZDOOHG PDLQWDLQDWOHDVWLQFKHVZDWHUFROXPQ 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 Walmart Supercenter #4696 1100388 02/09/2024 1 REG 5 Gal. 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Ext. Kisok Int. Kiosk Precision Testing Technologies Inc.02-09-24 1 S. Ext. Kiosk Max LaRou UT-412 □ □ □ □ □ □ □ □ □ Iii □ Iii □ Iii □ □ □ □ □ □ □ Iii □ ■ □ ■ □ □ □ □ □ □ □ Iii □ Iii □ Iii □ □ □ □ □ □ □ Iii □ Iii □ □ □ □ □ □ □ □ Iii □ ■ □ ■ □ □ □ □ □ □ □ Iii □ □ □ □ □ □ □ □ □ Iii □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ 02/09/24 11 :2 1 NA 885742 t,.MT #4696 1274 s . tftlV 189 H ber City, UT 840 32 Acti~e Alarm Report ' Q 5 ID • Diesel N, M2 Line LABEL --PERIODIC LINE FAIL DESCRIPTION II 02/06/24 1 :26P ACTI VE CLEAR • Q 4 -ID -Diesels . M1 Line LABEL • PERIODIC LINE FAIL DESCRIPTI ON • 02/05/24 ACTI VE • : CLEA R • f • 02/09/24 11:22 NA 885742 WMT #4696 1274 5. HWY 189 Heber City, UT 84032 CURRENT I NVENTORY REPORT TANK 1 : T1 Unleaded VOLUME = 15109 GALS 1001 ULLAGE= 4673 GALS 901 ULLAGE = 2695 GALS HEIGHT = 83.89 INCHES WATER = 0.00 INCHES WATER VOL = 0 GALS TEMP = 45.73 DEG F TANK 2 : T2 Unleaded VOLUME = 9156 GALS 1001 ULLAGE= 2748 GALS 901 ULLAGE = 1557 GALS HEIGHT = 84.04 INCHES WATER = 0.00 INCHES WATER VOL = 0 GALS TEMP = 46.75 DEG F TANK 3: T3 Premium VOLUME = 5508 GALS 1001 ULLAGE= 2393 GALS 90% ULLAGE = 1603 GALS HEIGHT = 77.79 INCHES WATER -0.00 INCHES WATER VOL -0 GALS TEMP = 45.41 DEG F TANK 4: T4 Diesel VOLUME - 1001 ULLAGE= 90" ULLAGE = HEIGHT = WATER - WATER VOL = TEMP = 5382 GALS 14400 GALS 12422 GALS 38. 10 INCHES 0.00 INCHES 0 GALS 45.56 DEG F 4 :46P • • 02/09/24 11 :22 AM 85742 WIIT 14696 1274 S. HWV 119 Heber City , UT 840J 2 -------·-··-·--------------·········-------------------- CONFIGURED : LABEL : PRODUCT CODE : PROB NUMB ER : PROBE OF FSET: FULL VOLUME : DIAMETER: TILT: THERMAL COEFFICIE NT: MET ER DATA PRESEN T: DELIV ERY DELAY : GROSS TEST FAIL: PERIODIC TEST FAIL : ANNU AL TES T FAIL: ••• TANK 1 ••• ENAB LED T1 Un l e ded 1 Pb 1 : Un l d Tk#1 Pr ob e 0.00 INCHES 19782 GALLONS 118,4 INCHES 0 .00 INC HES 0.000100 ENAB LED 5 MINUT ES ALARMS DISABLED GOST VOLU ME CORRECTION : ALARMS DISABLED ALARWS DISABLED DISABLED i CON FIG URED : LAB EL: PRODU CT COD E: PROBE NUMBER : PROBE OFFS ET: FULL VOLUME : DIAMETER : TIL T: THERMAL COEF FICI ENT : ME TER DATA PR ESEN T: DEL I VERY DE LAY : GROSS TEST FAI L: PERIOD I C TEST FAIL : ---TANK 2 --- ENABLED T2 Unl1aded 2 Pb 2: Unld Tk#2 Probe 0 .0Q INCHES 1190• GALLONS 118.4 INCHES 0.00 INC HES 0 .00 0,00 ENABLED S MIN UTES ALAR MS DISABLED ANNUAL TES T FAIL : GOS T VOLUME CORRECTION : ALAR MS DISABLED ALARM S DIS ABLED DI SABL ED CONFIGURED : LABEL : PRODUCT CODE : PROBE NUMBER : PROBE OFFSET: FULL VOLUME : DIAME TER: TILT : THERMAL COEF FICIENT: METER DATA PRESENT : DEL I VERY DELAY: GROSS TEST FAIL : PER I OD I C TEST FAIL: ---TANK 3 --- ENABLED T3 Premium 3 Pb 3 : Prem Tk#3 0.00 INCH ES 7901 GALLONS 118.4 INCHES 0.0Q INCHES 0.000100 ENABLED 5 MINUTES ALARMS DI SABLED Probe ANNUAL TEST FAIL: GOS T VOLUME CORRECTION : ALARMS DISABLED ALARMS DISABLED DISABLED CONFIGURED : LABEL : PRODUCT CODE : PROBE NUMBER : PROBE OFFSET : FULL VOLUME: DIAMETER: TILT: THERMAL COEFFICIENT : METER DATA PRESENT : DELIVERY DELAY : GROSS TEST FAIL: PERIODIC TEST FAIL: ---TANK 4 --- ENABLED T4 Di esel 4 Pb 4: Diesel Tk#4 Probe 0.00 INCHES 19782 GALLONS 118,4 INCHES 0 ,00 INCHES 0.000450 ENABLED 3 MINUTES ALARMS DISABLED ANNUAL TEST FAIL : GOST VOLUME CORRECTION : ALARMS DISABLED ALARMS DISABLED DISABLED \ • 02/0 9/24 11 :22 AM 88S742 Wt.IT #4696 1274 s. HWY 189 Heber City, UT 84032 ----~~~~--~------~-----------~ ---------------------~---••• TANK SETUP · LIMITS••• ·---------------------------·--------------------------· MAX VOL UM E: HIGH PRODUCT: DELI VERY OVE RFILL : DELI VERY LI MIT : LOW PRODU CT: HIG H WAT ER WARN I NG: HIG H WATE R ALARM : ---TA NK 1 --- 19782 GALLONS 951 901 151 536 GALLONS 1.00 I NCHES WATE R ALARM FI LT ER LEVEL: 3.00 INCHES LOW LE AK ALARM LI MIT: SUDD EN LOS S LIMIT : FUEL LOW TEMP LIM I T: FU EL HIGH TEMP LIMIT : MAX VOLUME : HIGH PRODUCT: DELIVERY OVERFILL: DELIVERY LIMIT: LOW PRODUCT : HIGH WATER WARNING : HIGH WATER ALARM: 15 GA LLONS 50 GALLONS -5 8 ,000 DEG F 140 .000 DEG F ---TANK 2 --- 11904 GAL LONS 951 901 151 536 GAL LONS 1.00 INCHE S WATER ALARM FILTER LEVEL : 3.00 INCH ES LOW LEAK ALARM LIMIT: SUDDEN LOSS LIMIT: FUEL LOW TEMP LIMIT : FUEL HIGH TEUP LIMIT: MAX VOLUME : HIGH PRODUCT : DELIVERY OVERFILL: DELIVERY LIMIT: LOW PRODUCT: HIGH WATER WARNING: HIGH WATER ALARM : 15 GALLONS SO GALLONS -58.000 DEG F 140.000 DEG F ---TANK 3 --- 7901 GALLONS 951 901 15% 536 GALLONS 1.00 INCHES WATER ALARM FILTER LEVEL: 3.00 INCHES LOW LEAK ALARM LIMIT: SUDDEN LOSS LIMIT : FUEL LOW TEMP LIMIT: FUEL HIGH TEMP LIMIT : MAX VOLUME: HIGH PRODUCT: DELIVERY OVERFILL : OELIVERY LIMIT : LOW PRODUCT : HIGH WATER WARNING: HIGH WATER ALARM : 1S GALLONS 50 GALLONS -58.000 DEG F 140 ,000 DEG F ---TANK 4 --- 19782 GALLONS 9S1 901 1S1 536 GALLONS 1,00 INCHES WATER ALARM FILTER LEVEL : 3.00 INCHES LOW LEAK ALARM LIMIT : SUDDEN LOSS LIMIT: FUEL LOW TEMP LIMIT: FUEL HIGH TEYP LIMI T: 15 GALLONS 50 GALLONS -58 .000 DEG F 140.000 DEG F 11 7 T #4 6 1274 S. HWY 189 Heber Ci ty, UT 84032 Sensor Status Report - All Sensors Sensor Location Stat us L 1 Unld. T1 STP Sum NORMAL L 2 Unld. T2 STP Sum NORMAL L 3 Prem, T3 STP Sum NORMAL L 4 DIE T4 STP Sump NORMAL L 5 Unld. T1 INT. Sp NORMAL L 6 Unld,Prem T2,T3 NORMAL L 7 DIE. T4 INT Spac NORMAL L 8 UDC FP 1,2 NORMAL L 9 UDC FP 3,4 NORMAL L 10 UDC FP 5,6 NORMAL L 11 UDC FP 7,8 NORMAL L 12 UDC FP 9,10 NORMAL L 13 UDC FP 11,12 NORMAL ' ' I I • 02/09/24 11:2 AM 88S742 WMT #4696 1274 S, HWV 189 Heber City, UT 84032 t PRESSURE LINE LEAK DIAGNOSTI C REPORT ◄ \ Line '\.Dispensing Test Status ----• -----------------------------Ln 1 : Unld 1 Line 0.0000 psi ENABLED Test complete Ln 2: Unld 2 Line 12.5840 psi ENABLED ~ \.. Ln 3: Prem Line 4.1200 psi ENABLED Ln 4: Diesels. M1 Line 1.4640 psi ENABLED Test complete Test complete - Test complete Ln 5: Diesel N. M2 Line 0.0000 psi ENABLED Test complete Pump Ha ndi.e -------·-- OFF OFF OFF OFF OFF OF F OFF OFF OFF OFF • • 02/09 /24 11 :59 AM 885742 \\'MT #4696 1274 S. HWY 189 Heber City, UT 84032 Sensor Status Report - All Sensors j # Sensor Location Status L 1 Unld. T1 STP Sum FUEL ALARM L 2 Unld. T2 STP Sum FUEL ALARM L 3 Prem. T3 STP Sum FUEL ALARM L 4 DIE T4 STP Sump FUEL ALARM L 5 Unld. T1 INT. Sp FUEL ALARM L 6 Unld,Prem T2,T3 FUEL ALARM ·L 7 DIE. T4 INT Spac FUEL ALARM L 8 UDC FP 1,2 FUEL ALARM L 9 UDC FP 3,4 FUEL ALARM L 10 UDC FP 5,6 FUEL ALARM L _11 UDC FP 7,8 FUEL ALARM L 12 UDC FP 9,10 FUEL ALARM L 13 UDC FP 11,12 FUEL ALARM I \ \ 88 574 2 WMT #4696 1 2 74 S . HWY 1 89 Heb e r City , UT 84 0 32 Acti ve Ala rm Report I D LAB EL DESC RIPTIO N ACTI VE CLEAR .ID LABE L DESCRIPTIO N ACTI VE CLEAR ID LAB EL DESCR IPTI ON ACTI VE CLEAR I D LABEL DESCRIPTION ACTIVE • CLEAR ID LABEL DESCR I PTION ACTIVE CLEAR I D LABEL DESCRIPTION ACTIVE CLEAR ID LABEL DESCRIP TION ACTIVE CLEAR ID LABEL DESCRIPTION iACTIVE CLEAR ID LABEL DESCRIPTION ACTIVE CLEAR ID LABEL DESCRIPTION ACTIVE CLEAR ID LABEL DESCRIPTION ACTIVE CLEAR ID LABEL DESCRIPTION ACTIVE CLEAR -------- ---------- ---------- --------- ---------- --------- -- ------ ---------- ---------- --------- ------ = -- = -------- T 4 T4 Diesel OVERFILL ALARM 02/09/24 1 :19P T 3 T3 Premium OVERFILL ALARM 02/09/24 1 :19P T 2 T2 Unleaded OVERFILL ALARM 02/09 /24 1:18P T 1 T1 Un lea ded OVE RFIL L ALARM 02/09/24 1 :18P T 3 T3 Premium HIGH WATER WARNING 02/09/24 1:0SP T 2 T2 Unleaded HIGH WATER ALARM 02/09/24 i:01P T 2 T2 Unleaded HIGH WATER WARNING 02/09/24 1:01P T 4 T4 Diesel HIGH WATER WARNING 02/09/24 1:00P T 1 T1 Unleaded HIGH WATER WARNING 02/09/24 12 :4SP Ln 1 Unld 1 Line LINE OUT 02/09/24 12:28P Q 1 Unld 1 Line PLLD SHUTOOtJN ALARM 02/09/24 12:28P Q , Unld 1 Line GROSS LINE FAIL 02/09/24 12:28P ID LABEL DESCRIPTION ACTIVE CLEAR ID LABEL DESC RIPTIO N ACTI VE CLE AR I D LAB EL DESC RI PTI ON ACTI VE CLEAR I D LAB EL DESC RIPTION ACT I VE CL EAR ID LABEL DESCRIPTION ACTIVE CLEAR ID LABEL DESCRIPTION ACTIVE CLEAR ID LABEL DESCRIPTION ACTIVE CLEAR ID LABEL DESCRIPTION ACTIVE CLEAR ID LABEL DESCRIPTION ACTIVE CLEAR ID LABEL DESCRIPTION ACTIVE CLEAR ID LABEL DESCRIPTION ACTIVE CLEAR ID LABEL DESCRIPTION ACTIVE CLEAR ID LABEL DESCRIPTION ACTIVE CLEAR ID LABEL DESCRIPTION ACTIVE CLEAR • • • • • • -- C • -- = = = -- = ------- --------- -------- ---------- - ------- --------- ---------- -------- C: -----' ----- --------- Ln 4 Diesel S. M1 Line LINE OUT 02/09/24 12 :26P Q 4 Diesel S. M1 Line PLLD SHUTOOtlN ALARM 02/09/24 12 :26P Q 4 Diesels. M1 Line GROSS LINE FAIL 02/09/24 12:26P Ln s Diesel N. M2 Line LI NE OUT 0 2/09 /24 12:23P Q 5 Di esel N. M2 Li ne PLLO SHUTDOWN ALARM 02/09/24 12 :23P Q 5 Diesel N. M2 Line GROSS LI NE FAIL 02/09/24 12:23P Ln 3 Prem Line LINE OUT 02/09/24 12:17P Q 3 Prem Line PLLD SHUTDOWN ALARM 02/09/24 12:17P Q 3 Prem Line GROSS LINE FAIL 02/09/24 12:17P Ln 2 Unld 2 Line LINE OUT 02/09/24 12:14P Q 2 Unld 2 Line PLLD SHUTDOWN ALARM 02/09/24 12: 14P Q 2 Unld 2 Line GROSS LINE FAIL 02/09/24 12: 14P Q s Diesel N. M2 Line PERIODIC LINE FAIL 02/06/24 1:26P Q 4 Diesels. M1 Line PERIODIC LINE FAIL 02/05/24 4:46P 12 7 4 S . HWY 189 Heber C~ty, UT 84032 CURRENT INVENTORY REPORT TANK 1 : T1 Unleaded VOLUME C 100~ ULLAGE= 15143 GALS 90~ ULLAGE C 4639 GALS HEIGHT = 2661 GALS WATER _ 84.06 INOiES WATER VOL -0.00 I NCHE S = 0 GALS TEMP = 45.69 DEG F TANK 2: T2 Unleaded VOLUME c: 1001 ULLAGE = 901 ULLAG E = HEIGHT = WATER = WATER VOL = TEMP = 9126 GALS 2778 GALS 1S87 GALS 83 ,79 INCHES 0 ,00 INCHES 0 GALS 46 .71 DEG F TANK 3 : T3 Premium VOLUM E = 5452 GALS 100~ ULLAGE = 2449 GALS 90~ ULLAG E = 1659 GALS HEIGHT = 77.1 0 I NCHES WAT ER = 0.00 I NCH ES WATER VOL = 0 GALS TEMP = 45 .42 DEG F TANK 4 : T4 Diesel VOLUME = 5416 GALS 1001 ULLAGE= 14366 GALS 90% ULLAGE = 12387 GALS HEIGHT = 38 .28 INOiES WATER = 0.00 INCHES WATER VOL = 0 GALS TEMP = 45.51 DEG F tAANIFOLDED TANKS INVENTORY TOTALS T 1 :11 Unleaded T 2 :T2 Unleaded VOLUME = 24270 GALLONS • 02/09/24 4 :22 PM 885742 'tJMT #4696 1274 S. HWY 189 Heber City, UT 84032 Active Alarm Report --Q s ID Diesel N. M2 Line LABEL --PERIODIC LINE FAIL DESCRIPTION ::: 02/06/24 1 :26P ACTIVE = CLEAR = Q 4 --Diesels. Mi Line ID = LABEL PERIODIC LINE FAIL -DESCRIPTION -02/05/24 4:46P ACTIVE = CLEAR -- FORM 1 SUMMARY OF SOURCE TEST DATA SOURCE INFORMATION FACILITY PARAMETERS GDF Name and addresss GDF Representative and Title _________________________________ PHASE II SYSTEM TYPE (Check One) Balance ____ Hirt ____ Red Jacket ____ Hasstech ____ Healy ____Other GDF Phone No. (___)________________ Permit Conditions Source: GDF Vapor Recovery System GDF # A/C # Manifolded? Y or N Operating Parameters Number of Nozzles Served by Tank #1 ______ Number of Nozzles Served by Tank #3 ______ Number of Nozzles Served by Tank #2 ______ Number of Nozzles Served by Tank #4 ______ Applicable Regulations: VN Recommended Source Test Results and Comments Tank #: 1.Product Grade 2.Actual Tank Capacity, gallons 3.Gasoline Volume 4.Ullage, gallons (#2-#3) 5.Initial Pressure, inches H 2 O 6.Pressure After 1 Minute, inches H 2 O 7.Pressure After 2 Minutes, inches H 2 O 8.Pressure After 3 Minutes, inches H 2 O 9.Pressure After 4 Minutes, inches H 2 O 10.Final Pressure After 5 Minutes, inches H 2 O 11.Allowable Final Pressure Test Conducted by: Test Company: Date of Test: California Air Resources Board July 26, 2012 TP-201.3, Page 14 40CFR63CCCCCC Precision Testing Technologies Walmart #4696 1274 S. U.S. Hwy. 189 Heber City, UT V.R.S. Dual Point 4 1 REG 19,782 15,109 2 REG 11,904 9,156 3 PRM 7,901 5,508 Manifold 9,814 2.00 1.96 1.93 1.91 1.90 1.89 1.85 Max LaRou UT-412 02/09/2024 Walmart #4696 1274 S. U.S. Hwy. 189 □ □ 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 Walmart Supercenter #4696 1274 S. U.S. Hwy. 189 Heber City, UT 09/02/2024 Max LaRou UT-412 REG1/REG2/PRM Husky 5885 4 0.04 cfh @ 2"wc 3.4"wc 0.18 cfh @ 4"wc -7.3"wc Walmart Supercenter #4696 1274 S. U.S. Hwy. 189 Max LaRou UT-412 09/02/2024 Heber City, UT LJ □ □ □ □□ □ □ Testing and Inspection Certificate Tanknology Inc. 11000 North MoPac Expressway, Suite 500, Austin, TX 78759 800-800-4633 www.tanknology.com Page 1 of 1 Test Date 1/18/2024 Tanknology WO#NW1-2364466 Test Purpose POST CONST Customer PO#38390783 Customer Location SAM'S CLUB 2001 S.E. 10TH STREET DEPT. # 449562 BENTONVILLE, AR 72716 WALMART #WM4696 1274 S US 189 BLVD B HEBER CITY, UT 84032 Attn: PROJECT MANAGER Attn: Asset Protection Manager (479) 204-3407 () Test / Inspection Description Item Tested Date Tested Result PEI RP 1200 Sump Testing See test report for details 1/18/2024 Pass PEI RP 1200 Sump Testing See test report for details 1/18/2024 Pass Line Interstitial 1 1/18/2024 P Line Interstitial 2 1/18/2024 P Line Interstitial 3 1/18/2024 P Line Interstitial 4 1/18/2024 P Tanknology Representative: David Edens Technician: David Mathie Telephone: ()Technician Certification: (See forms) Tanknology WALMART #WM4696 1274 S US 189 BLVD B HEBER CITY UT 84032 WM4696 Tanknology, Inc. SAM'S CLUB 2001 S.E. 10TH STREET DEPT. # 449562 BENTONVILLE AR 72716 479-204-3407 01/18/2024 FRP 40 20 24 1309 24 1409 1 HR 0 FRP 41 21 25 1315 25 1415 1 HR 0 FRP 40 20 24 1305 24 1405 1 HR 0 FRP 40 20 24 1300 24 1400 1 HR 0 Tank 1 STP Sump 1 Tank 2 STP Sump 1 Tank 3 STP Sump 1 Tank 4 STP Sump 1 UT151 David Mathie NW1-2364466 Rernmmertdoo Practices for the Jesting and VertfficaU on of Sp3lt Overfill ~ Leak Detection and Secondary Contai11ment Eq uipmen t at UST Fa ci!iies APPENDIX ,c-4 CONTAINME 1NT SUMP' INTE1GRITY TESTING HYDRO,STATIC TESTING METHOD, --------~ ------------------------~ Fa cil ity a m e: Own er: Address: Add ress: 1 I City, Stat,e Zi p Code: City, State Zip Code: I I Fa cil i , I.D. : p 0 e I Testing C mpany: Pho e Dat e: Th is pro ce dure is to est t · e lea k integrity of co 11tai • mer t su m ps. See PE I/R P1200 Sectio n 6.5 for he t est n1 e h d. I I I I Co nta i nm,ent Su p lD I I Car ta i11m ,ent Su 1p M at e ri a l I l iquid a ndi d,ebri s 0 Yes 0 No 0 Yes removed fr m su m p? □ 0 0 Yes □ 0 0 Yres □ 0 □Yes □. 0 D ,.es □ 0 I Vi sual ln spectio (N cracks, I ose parts 0 Pass □Fa i l 0 Pass □Fai l 0 Pass □I Fa il or sepa ratio 11 of h,e □ ass □ ail □Pass □ ail □ ass □Fa i l co ntai n ment su m p.) Conta inment Su p I I Depth Hei ght Fro m 8 tt m t "f;p f H ig es Pe n e .ra ti 11 I I sta Iii 11 g Water Leve l I Tes Start Ti me I Er d in g Wa er Leve l j 2:=,st nd Tim e Tes e riod (Minirrmm ,est ti m e : 1 h ur) I Water Le ve 11 Change I P~ss/fai l cri eria: Must pa ss v isual in spectio . Water le ve l drnp o · less thar 1/8 inc h. Test R,esults 0 P~ss □Fa i l 0 Pass □Fai l 10 Pass □Fai l 0 ass □ ail, □Pass □Fail □P ass □Fai l I Commemts: I * Al I I iq ids a d d,ebr i s must be d is posed of properly_ Teste r's Na m e (p ·nt) ______________ _ Tester s Signature _JJ_/; ____________ _ pei.org 4D WALMART #WM4696 1274 S US 189 BLVD B HEBER CITY UT 84032 WM4696 Tanknology, Inc. SAM'S CLUB 2001 S.E. 10TH STREET DEPT. # 449562 BENTONVILLE AR 72716 479-204-3407 01/18/2024 FRP 16.5 7 11 1322 11 1422 1 HR 0 FRP 16.5 7 11 1322 11 1422 1 HR 0 FRP 16.5 7 11 1322 11 1422 1 HR 0 FRP 16.5 7 11 1333 11 1433 1 HR 0 FRP 16.5 7 11 1333 11 1433 1 HR 0 1/2 3/4 5/6 7/8 9/10 11/12 FRP 16.5 7 11 1333 11 1433 1 HR 0 UT151 David Mathie NW1-2364466 Rernmmertdoo Practices for the Jesting and VertfficaU on of Sp3lt Overfill ~ Leak Detection and Secondary Contai11ment Eq uipmen t at UST Fa ci!iies APPENDIX ,c-4 CONTAINME 1NT SUMP' INTE1GRITY TESTING HYDRO,STATIC TESTING METHOD, --------~ ------------------------~ Fa cil ity a m e: Own er: Address: Add ress: 1 I City, Stat,e Zi p Code: City, State Zip Code: I I Fa cil i , I.D. : p 0 e I Testing C mpany: Pho e Dat e: Th is pro ce dure is to est t · e lea k integrity of co 11tai • mer t su m ps. See PE I/R P1200 Sectio n 6.5 for he t est n1 e h d. I I I I Co nta i nm,ent Su p lD I I Car ta i11m ,ent Su 1p M at e ri a l I l iquid a ndi d,ebri s 0 Yes 0 No 0 Yes removed fr m su m p? □ 0 0 Yes □ 0 0 Yres □ 0 0 Yes □. 0 0 ,.es □ 0 I Vi sual ln spectio (N cracks, I ose parts 0 Pass □Fa i l 0 Pass □Fai l 0 Pass □I Fa il or sepa ratio 11 of h,e 0 ass □ ail 0 Pass □ ail 0 ass □Fa i l co ntai n ment su m p.) Conta inment Su p I I Depth Hei ght Fro m 8 tt m t "f;p f H ig es Pe n e .ra ti 11 I I sta Iii 11 g Water Leve l I Tes Start Ti me I Er d in g Wa er Leve l j 2:=,st nd Tim e Tes e riod (Minirrmm ,est ti m e : 1 h ur) I Water Le ve 11 Change I P~ss/fai l cri eria: Must pa ss v isual in spectio . Water le ve l drnp o · less thar 1/8 inc h. Test R,esu lts 0 P~ss □Fa i l 0 Pass □Fai l 10 Pass □Fai l 0 ass □ ail, 0 Pass □Fail 0 Pass □Fai l I Commemts: I * Al I I iq ids a d d,ebr i s must be d is posed of properly_ Teste r's Na m e (p ·nt) ______________ _ Tester s Signature _JJ_/; ____________ _ pe i.org 4D Site Diagram (This site diagram is for reference only and is not drawn to scale) Work Order:2364466 Site ID / Name:WM4696 / WALMART #WM4696 Address:1274 S US 189 BLVD B City:HEBER CITY State:UT Zip:84032 Tanknology (e 9 ~ $ ~ ~ sJ K ES O ~ ~ ~ W.O.# NW1-2364466 Cust Ref#: 38390783 LINE INTER APPENDIX C-2 PIPING SECONDARY CONTAINMENT INTEGRITY TESTING ., Facility Name: WAL MART 4696 Own er: Ad dress: 1274 S US189 BLVD B Address: City, State, Zi p Coclc: HEBER Ci ty, State, Zip Code: Facilit y I.D. #: Ph one#: Test i ng Company: TANKNOLOGY Ph one#: 801-831-7097 Date: 1-18-24 This proced ure is to test the integrity of the interstitia l space of double-wa lled p ipi ng. See PEI/RP1200, Section 5 for t he t est procedure. Tank Num ber 1&2 3 4 Pipi ng Run ALL ALL ALL Piping Materia l FLEX FLEX FLEX Prod uct Stored RUL PREM DSL Test Start Time \'7 tJ.,.'j \'7 0-S.. \ '7 c-.,,< I nitial Test Press ure , psig (Test procedure specif ies 5 5 5 5 psig.) Test End Tim e \,7~ \'3½ \ 's--S,'s Fin al Test Pressure, psig 5 5 5 Pr essure Change (No reduct ion in pressure /JI / ;x j-al lowed for pass.) Test Results D Pass □Fa il J'.:l Pass D Fail D Pass □Fa ll □ Pass □ Fa il D Pass D Fa il D Pass D Fa il Comments: LINE JUMPERED ENDS DISP 7/8 BOTHRULANDSYPHONEJUMPEREDTOGETHER - UT151 DAVE MATHIE \\ ;,1 Tester's Name Tester's Signa~,, l A if t,, ,. --- [ ____ __ W.O.# NW1-2364466 Cust Ref#: 38390783 OVF Sl Ta nknology Inc. Pol i cy I 00-29-A 1 1000 N. M oPac Express wa y, Suite 500 Austin, TX 78759 (800) 964-0010 Rev: H JOB CLEARANCE FORM & SITE SAFETY CHECKLIST -OVF Revised : 6/25/2022 Date l,---\@- Scop e of Work and Tasks Performed (JSA·s m ust be available for all tasks): Repairs lo Equipment or Parts Provided; Follow-up actio ns required: equipment Isolated: comments: PPE -PERSONAL PROTECTIVE EQUIPMENT REQUIRED Check ✓items used or mark -if not a /icable fety Ve sUShirt (all jobs) Ge: Gloves (all job s) D Splas h Goggles (if needed ) D Hea ri ng Prot ection (if needed ) Safety Toe Boots (all jobs) Gr'safety Glasses (all jobs) ~d Hat (if needed ) D Other ✓ PRE -TEST PROCEDURES (Check ✓ each item completed or mark -if no t applicable/ 1. J Discuss safety proced ures with site personnel. Ne arest hos pi ta l: __________________ _ 2. LJ Get ATG printou t & check fue l/wa ter leve ls. Prior to f ue l deli ve ry the system must be placed back into worki ng orde r. 3. :1 Ba rricade work area (cones, fiags , bars/tape) an d place Fire Extinguish ers & "No Smoking" Signs at perimeter. 4. J Confin ed S pace En try -If requ ired complete separate CSE Checklist. If NO CSE check the fo llowing reason: r 1No CS's C CS's not opened ~ n No entry only vi sual ONo entry -use d tools C!Work from prone position w/o risk of fall ing in 5. l::J Implement LockouVTagout per API 1646 (when acces sing product piping during ta sk s ) 0 Secure nozzles with uo ut Ot Serv ice" bags and nylon ties. 0 Secure the circuit breaker(s) with lockout devices an d tags. D Close ball valves or c he ck valves on product piping. D All applicable equipment disabled during test(s). General Safety Checks: All site personnel have been informe d. Is a fuel deli very d ue today? -,,-----,----- LOT O procer::!ures have been d iscussed . Work areas barricaded to protect workers, staff & publ ic. J Disconnect electrical "bay onet' connecto r from the STP(s). D Verify LOTO is complete by trying to operate pumps. Lead Technician Name Lead Technician Signature Site Representative Name Sita Representative Signature ✓ POST-TEST PROCEDURES (Check ✓ each item completed or mark -if not applicable) 1. 2. LI Remove all "Lockout/Tagout" devices and nozzle bags/ties . □ Ru n all pum ps and ve rify the re are no leaks: n Impact Valve Test Po rts unde r dispensers I~ Leak Dete ctor & Vent Tube s C STP Functional Ele ments & Re li ef Scre ws 3. 4 . [ Get ATG pri nto ut. Confirm wa ter levels sam e as sta rt or explain difference : ______________ _ 5 . L Check followin g com ponents o perational : f l ATG probes , sensors, & caps O Ball fi oats, dry breaks & caps D Contai nment sumps are dry O Man hole covers and sump lid s l 1 Sp ill co ntainers & drain valves L Drop tubes, fiapper valves, fi ll adapters & caps :J Remove barricades. . SIG N 01ff& 0 ~--rator Ve rification ofWQrlf 0 Gener al Sa f et y Checks: Work area has b een l eft clean & safe. Site staff aware of work status including any rem aining isola • Chang es to equipment are documented and comm unic at ed. All incide nts, near incid ents, and unsafe situations reported. Site Representative Comments: COMPANY CONFIDENTIAL u Shear valves are ope n I , Di spensers & POS operational l·: Dispenser pan els are replaced Ll Ven ts & Extracto rs (not capped , pl ugg ed or isolated ) !J Cathodic protection operati onal .J Siphon lines and man ifold va lves open ec nician Signature Site Representati ve Signature © Tanknol ogy Inc., :!022. A ll Rights Re.served . IPrin led copies of thi s doc.:ument are uncontrollc:d. T he cu rrent version is avai lable in the Tanknology On-Line Docu men 1 Control Sys1em.l '---------...J