DERR-2024-009982

WESTECH EQUIPMENT
195 WEST 3900 SOUTH • P.O. BOX 57307 • SALT LAKE CITY, UTAH 84157-0307
801-266-2545 • TOLL FREE 800-433-8831 • 24 HOUR FAX [phone]

SPILL BUCKET INTEGRITY TESTING HYDROSTATIC TEST METHOD
SINGLE- AND DOUBLE-WALLED VACUUM TEST METHOD
Facility Name: Smith’s #475 Owner: Smith’s Food and Drug Centers, Inc.
Address: 3171 East 3300 South Address: P.O. Box 305103
City, State, Zip: Salt Lake City, Utah 84109 City, State, Zip: Nashville, Tennessee 37230
Facility I.D.#: 4002338 Phone #: [phone]
Testing Company: Westech Phone #: [phone] Date: 4/9/24
This procedure is to test the leak integrity of single- and double-walled spill buckets. See PEI/RP1200 Section 6.2 for hydrostatic test
method, Section 6.3 for single-walled vacuum test method and Section 6.4 for double-walled vacuum test method.
Tank Number 1 (South)
Product Stored RUL
Spill Bucket
Capacity 5-Gallon
Manufacturer OPW
Construction ☒Double-walled
☐Single-walled
☐Double-walled
☐Single-walled
☐Double-walled
☐Single-walled
☐Double-walled
☐Single-walled
Test Type
☒Hydrostatic
☐Vacuum
☐Double-walled
☐Single-walled
☐Hydrostatic
☐Vacuum
☐Double-walled
☐Single-walled
☐Hydrostatic
☐Vacuum
☐Double-walled
☐Single-walled
☐Hydrostatic
☐Vacuum
☐Double-walled
☐Single-walled
Spill Bucket Type ☒Product
☐Vapor
☐Product
☐Vapor
☐Product
☐Vapor
☐Product
☐Vapor
Liquid and debris remove from spill
bucket?* ☒Yes ☐No ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No
Visual Inspection (no cracks, loose
parts or separation of the bucket from
the fill pipe.)
☒Yes ☐No ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No
Tank Riser cap included in test? ☒Yes ☐No
☐NA
☐Yes ☐No
☐NA
☐Yes ☐No
☐NA
☐Yes ☐No
☐NA
Drain valve included in test? ☐Yes ☐No
☒NA
☐Yes ☐No
☐NA
☐Yes ☐No
☐NA
☐Yes ☐No
☐NA
Starting Level 11 7/8”
Test Start Time 2:24
Ending Level 11 7/8”
Test End Time 3:24
Test Period 1 Hour
Level Change 0”
Pass/fail criteria: Must pass visual inspection. Hydrostatic: Water level drop of less than 1/8 inch; Vacuum single-walled only: Maintain at least 26 inches water
column; Vacuum double-walled: maintain at least 12 inches water column.
Test Results ☒Pass ☐Fail ☐Pass ☐Fail ☐Pass ☐Fail ☐Pass ☐Fail
Comments: RUL (south) inner bucket replaced and retested on 4/9/24.
*All liquids and debris must be disposed of properly
Tester’s Name Sean Jardine, UT-0397 Tester’s Signature

WESTECH EQUIPMENT
195 WEST 3900 SOUTH • P.O. BOX 57307 • SALT LAKE CITY, UTAH 84157-0307
801-266-2545 • TOLL FREE 800-433-8831 • 24 HOUR FAX [phone]

UST OVERFILL EQUIPMENT INSPECTION
AUTOMATIC SHUTOFF DEVICE AND BALL FLOAT VALVE
Facility Name: Smith’s #475 Owner: Smith’s Food and Drug Centers, Inc.
Address: 3171 East 3300 South Address: P.O. Box 305103
City, State, Zip: Salt Lake City, Utah 84109 City, State, Zip: Nashville, Tennessee 37230
Facility I.D.#: 4002338 Phone #: [phone]
Testing Company: Westech Phone #: [phone] Date: 4/9/24
This data sheet is for inspecting automatic shutoff devices and ball float valve. See PEI/RP1200 Section 7 for inspection procedures.
Product Grade RUL
Tank Number 1 (South)
Tank Volume, gallons 19,703
Tank Diameter, inches 117 3/4
Overfill Prevention Device Brand OPW
Type ☒ Automatic
Shutoff Device☐
Ball Float
Valve
☐ Automatic
Shutoff Device
☐ Ball Float
Valve
☐ Automatic
Shutoff Device
☐ Ball Float
Valve
☐ Automatic
Shutoff Device
☐ Ball Float
Valve
AUTOMATIC SHUTOFF DEVICE INSPECTION
1. Drop tube removed from tank? ☒Yes ☐No ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No
2. Drop tube and float mechanisms free of debris? ☒Yes ☐No ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No
3. Float moves freely without binding and poppet moves
into flow path? ☒Yes ☐No ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No
4. Bypass valve in the drop tube open and free of
blockage (if present)?
☒Yes ☐No
☐Not Present
☐Yes ☐No
☐Not Present
☐Yes ☐No
☐Not Present
☐Yes ☐No
☐Not Present
5. Flapper adjusted to shut off flow at 95% capacity? * ☒Yes ☐No ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No
A "No" to any item in Lines 1-5 indicates a test failure.
BALL FLOAT VALVE INSPECTION**
1. Tank top fitting vapor-tight and leak free? ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No
2. Ball float cage free of debris? ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No
3. Ball free of holes and cracks and moves freely in cage? ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No
4. Vent hole in pipe open and near top of tank? ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No
5. Ball float pipe proper length to restrict flow to 90%
capacity? *** ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No
A "No" to any item in Lines 1-5 indicates a test failure.
Test Results ☒Pass ☐Fail ☐Pass ☐Fail ☐Pass ☐Fail ☐Pass ☐Fail
Comments: Drop tube replaced and retested on 4/9/24.
*Use manufacturer’s suggested procedure for determining if automatic shutoff device will shut off flow at 95% capacity.
**If a ball float valve is found to fail the inspection, another method of overfill must be used.
***Use manufacturer’s suggested procedure for determining if flow restriction device will restrict flow at 90% capacity.
Tester’s Name Sean Jardine, UT-0397 Tester’s Signature