DERR-2024-004585

APPLIED ENVIRONMENTAL SERVICES, L.C.
PO BOX 1073 BOUNTIFUL, UTAH 84011 801-540-9258
T.E.I. SYSTEM 4000 / T.E.I. LT3 / T.E.I. ULLAGE
PRECISION TANK & LINE TEST RESULTS SUMMARY
INVOICE ADDRESS: TANK LOCATION: WORK ORDER #
TECH # 94027 VAN # 8502
TECHNICIAN: SM
STATE TECH #
STATE FUEL NETWORK
PO BOX 141152
SALT LAKE CITY, UTAH 84141-1152
UTAH DOT#436 # 5000215
250 SOUTH 200 EAST
EMERY, UTAH
24006
UT 0121
DATE:2-20-2024 TIME START: TIME END: GROUNDWATER DEPTH:
TIME SYSTEM FILLED OR TOPPED:
TANK TANK
CAPACITY
2000
4000
PRODUCT
R/UL
DSL
TANK VENT PRODUCT
LINE
PASS
PASS
LINE LEAK
DETECTOR
PASS
PASS
WATER IN
TANK
PUMP
TYPE
PRESS
PRESS
TANK
MATERIAL
CONVAULT
CONVAULT
1
2
3
4
5
6
PRODUCT LINES TESTED AT 50 PSI FOR 15 MINUTES
LINE RATES (GPH)
1
2
3
4
5
6
R/UL -.007
DSL -.004
ADDITIONAL INFORMATION:MECHANICAL LINE LEAK DETECTORS PASS 3 GPH SIMULATED LEAK TEST
ABOVEGROUND TANKS WITH UNDERGROUND PRODUCT LINES
CERTIFIED TECHNICIAN SIGNATURE: DATE:2-20-2024
All tests are performed in a professional manner, and within common practices of the industry. However due to the
variables of tank testing, these results cannot be guaranteed. There are no warranties expressed, written or implied.
These systems meet all requirements set forth by USEPA 40 CFR and has recieved third party certification.
Digitally signed by STEVEN B MARTIN
cn=STEVEN B MARTIN, o=AES, c=US
Date: 2024.02.26 10:06:18 -07'00'
Reason: I am the author of this document
SPILL PREVENTION TEST
Spill Bucket Hydrostatic Test Form
Facility Name Facility ID
Address Tester's Name
Test Date Phone
Tank Number
Product Stored
Capacity
Manufacturer
Construction
Liquid and Debris
Removed
Visual Inspection
No cracks, holes,
or separations
Tank Riser Cap
Included in Test
Is Drain Valve
Included in Test
Start Level
Start Time
Ending Level
End Time
Test Period
(minimum of 1 hour)
Change in Level
Test Results
Photos indicating water
Levels are Attached?
Pass / Fail Criteria: Must pass visual inspection, test duration at least one hour, must include photos with this
form, water level drop of less than 1/8 inch. Ref: PEI / RP 1200 6.2.5 Test Procedure
How was Liquid Disposed?
Comments
I certify under penalty of law that the above information is true, accurate and complete
Tester's Signature
UTAH DOT # 436 5000215
250 SOUTH 200 EAST
EMERY, UTAH
STEVEN MARTIN AES TESTING UT 0121
2-20-2024 801-540-9258
1
R/UL
5 G
CONVAULT
SWS
YES
PASS
YES
YES
11 1/2
11:16
11 1/2
12:16
1 HR
0
PASS
NO
2
DSL
5 G
CONVAULT
SWS
YES
PASS
YES
YES
11 1/8
11:16
11 1/8
12:16
1 HR
0
PASS
NO
REUSED
CONVAULT TANKS WITH BUILT IN SPILL CONTAINMENTS
Digitally signed by STEVEN B MARTIN
cn=STEVEN B MARTIN, o=AES, c=US
Date: 2024.02.26 10:43:00 -07'00'
Reason: I am the author of this document
UTAH STATE FUEL NETWORK AST ANNUAL INSPECTION
Facility Name and Site Address: Date:
Facility ID #
Purpose:Regular Reinspection Complaints Annual Inspection
Nu
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Pumps Tested for Calibration
Is tank grounding strap in good condition ?
Is tank coating free of corrosion / damage ?
Is tank free of noticable distortion, denting, buckeling ?
Flanged connection bolts appear tight ?
Normal and emergency vents appear in good condition ?
Inspection Remarks:
Technician signature
Inspected By: Steven B. Martin UT121
Applied Environmental Services L.C.
UTAH DOT # 436
250 SOUTH 200 EAST
EMERY, UTAH
2-20-2024
5000215
X
1-2 X X
X
X
X
X NO DEDICATED GROUND STRAPS
X
X
N/A
X
XNO
X
State Fuel Contact : Brett Gurney 385-602-4872
801-540 9258 [e-mail]
Email: [e-mail]
X
X
X
X
X
X
X
X
Fill and vapor connections in good condition ?
CONVAULT ASTS WITH UNDERGROUND PRODUCT LINES
CRACKS AND FLAKING IN CONCRETE COATING ON CONVAULT TANKS
XTank containment structure in satisfactory condition ?
Free of tank settlement and foundation washout ?
Tank supports in satisfactory condition ?
Is water able to drain off tank pad and tank top ?
Gasoline vent has P/V valve installed where required ?
Valves / syphons / solenoids appear in good condition ?
Spill containment visable and appears in good condition
Electrical junction boxes and conduits in good condition
Tank monitor free of active alarms ?
Emergency shutoff installed ?
Dispenser static test ?
Tank overfill equipment installed ?
Piping sumps appear in good condition ?
COMMENTS / ACTION
Digitally signed by STEVEN B MARTIN
cn=STEVEN B MARTIN, o=AES, c=US
Date: 2024.02.26 10:16:00 -07'00'
Reason: I am the author of this document