DERR-2024-010338

Annual Sump Inspection
PV VENT CAP
STAGE 1 PD
11000 N. MoPac Expressway, Suite 500
Austin, Texas 78759
Phone: [phone]
Fax: [phone] Date Printed and Mailed: 8/24/2024
UTAH DEPARTMENT OF ENV. QUALITY
UST
PO Box 144840
SALT LAKE CITY, UT 84114
Test Date: 7/30/2024
Order Number: 2372539
Dear Regulator,
Enclosed are the results of recent testing performed at the following facility:
Jackson Foods #161
1567 S. Creek Meadow Rd.
Riverton, UT 84065
Testing performed:
Sincerely,
Dawn Kohlmeyer
Manager, Field Reporting
2 inch Pressure Decay Test
TP201.3

Store Information Testing Company
Site Name :Jackson Foods #161 Name :TANKNOLOGY INC.
Address :1567 S. Creek Meadow Rd.
Riverton, UT 84065
Address :11000 N. MoPac Expressway Suite 500
Austin, TX 78759
Phone :-Phone :[phone]

Stage I System?DUAL
Stage II System?NONE
Total # of Nozzles :4
Products per Nozzle :1
Tanks Manifolded ?No
Drop-Out tank present?N0
Total # of Tanks Tested :1

Tank Information :
Product Grade :
Tank Capacity, gallons :
Gasoline, gallons :
Ullage, gallons :
Testing Information :
Start Time :
Initial Pressure, wcg :
Pressure @ 1 minute(s) :
Pressure @ 2 minutes :
Pressure @ 3 minutes :
Pressure @ 4 minutes :
Pressure @ 5 minutes :
Allowable Final Pressure :
Pass/Fail (Enter "GF" Gross Failure)
4 E-FREE
REG - CONV(E0)
9753
1965
7788

12:30
2.00
2.00
2.00
2.00
2.00
2.00
1.88
Pass

Total

9753
1965
7788
All

Comments:

Tester :David Mathie Test Date :7/30/2024
Signature :Work Order :2372539

WO: 2372539
PVVC tested ==>RUL Manifolded
Final Test Result (Pass / Fail) ==>Pass
PVVC Manuf. ==>OPW Model Number ==>723V
Is this Original or
Replacement?
Original
If this cap is being
replaced, check here:
Manf Spec
(CFH)
Measured
Leak Rate
in ml/Min;
Cracking
(in H2O)
Calc CFH
(ml/min
x
.00212)
Result
(Pass /Fail)
Pos Leak Rate(CFH)0.05 5 0.0106 Pass
Low High Measured
Pos Cracking (in H2O)2.50 6.00 3.47 Pass
Neg Leak Rate (CFH)0.21 17 0.0360 Pass
Low High Measured
Neg Cracking (in H2O)-10.00 -6.00 -6.86 Pass
PVVC tested ==>PREM Manifolded
Final Test Result (Pass / Fail) ==>Pass
PVVC Manuf. ==>OPW Model Number ==>723V
Is this Original or
Replacement?
Original
If this cap is being
replaced, check here:
Manf Spec
(CFH)
Measured
Leak Rate
in ml/Min;
Cracking
(in H2O)
Calc CFH
(ml/min
x
.00212)
Result
(Pass /Fail)
Pos Leak Rate(CFH)0.05 6 0.0127 Pass
Low High Measured
Pos Cracking (in H2O)2.50 6.00 3.52 Pass
Neg Leak Rate (CFH)0.21 16 0.0339 Pass
Low High Measured
Neg Cracking (in H2O)-10.00 -6.00 -6.90 Pass
PVVC tested ==>EFREE Manifolded
Final Test Result (Pass / Fail) ==>Pass
PVVC Manuf. ==>OPW Model Number ==>723V
Is this Original or
Replacement?
Original
If this cap is being
replaced, check here:
Manf Spec
(CFH)
Measured
Leak Rate
in ml/Min;
Cracking
(in H2O)
Calc CFH
(ml/min
x
.00212)
Result
(Pass /Fail)
Pos Leak Rate(CFH)0.05 5 0.0106 Pass
Low High Measured
Pos Cracking (in H2O)2.50 6.00 3.53 Pass
Neg Leak Rate (CFH)0.21 15 0.0318 Pass
Low High Measured
Neg Cracking (in H2O)-10.00 -6.00 -6.86 Pass
PVVC tested ==> Manifolded
Final Test Result (Pass / Fail) ==>
PVVC Manuf. ==>Model Number ==>
Is this Original or
Replacement?
Manf Spec
(CFH)
Measured
Leak Rate
in ml/Min;
Cracking
(in H2O)
Calc CFH
(ml/min
x
.00212)
Result
(Pass /Fail)
Pos Leak Rate(CFH)
Low High Measured
Pos Cracking (in H2O)
Neg Leak Rate (CFH)
Low High Measured
Neg Cracking (in H2O)
PVVC tested ==> Manifolded
Final Test Result (Pass / Fail) ==>
PVVC Manuf. ==>Model Number ==>
Is this Original or
Replacement?
Manf Spec
(CFH)
Measured
Leak Rate
in ml/Min;
Cracking
(in H2O)
Calc CFH
(ml/min
x
.00212)
Result
(Pass /Fail)
Pos Leak Rate(CFH)
Low High Measured
Pos Cracking (in H2O)
Neg Leak Rate (CFH)
Low High Measured
Neg Cracking (in H2O)
PVVC tested ==> Manifolded
Final Test Result (Pass / Fail) ==>
PVVC Manuf. ==>Model Number ==>
Is this Original or
Replacement?
Manf Spec
(CFH)
Measured
Leak Rate
in ml/Min;
Cracking
(in H2O)
Calc CFH
(ml/min
x
.00212)
Result
(Pass /Fail)
Pos Leak Rate(CFH)
Low High Measured
Pos Cracking (in H2O)
Neg Leak Rate (CFH)
Low High Measured
Neg Cracking (in H2O)
11000 N. MOPAC EXPRESSWAY, SUITE 500, AUSTIN, TX 78759
[phone]
QP-08-03-FF-02 Pressure Vacuum Vent Cap TP-201.1E Field Form
Rev C 1/27/2011
Site Overall Test Results: Pass
Total +ve LR: 0.0339
Total -ve LR: 0.1017

Test Date 7/30/2024
Technician Name David Mathie
WO #2372539
Facility Name / Loc #Jackson Foods #161 161
Street 1567 S. Creek Meadow Rd.
City, St, Zip Riverton, UT 84065

Pressure Vacuum Vent Cap Test Form TP-201.1E

ANNUAL CONTAINMENT SUMP INSPECTION
This form may be utilized to document the inspection of containment sumps.
Date of Inspection
7/30/2024
UST Facility Person Conducting Test
Facility Name
Jackson Foods #161
Facility ID #
161
Tester's Name
DMATHIE
Physical Address
1567 S. Creek Meadow Rd.
Company
Tanknology Inc.
City
Riverton
County
SALT LAKE
State
UT
Certification #
41442
Expiration Date
10/20/2025
UST Owner
JACKSONS FOOD STORES
Tester's Signature Date
7/30/2024
Containment Sump Inspection
Sump Material
of Construction Fiberglass Reinforced Plastic Thermoplastic Steel Composite
Containment Sump Inspection Procedure
1. Clean-out and properly dispose of all debris, soil and/or fluids from the containment sump.
2. Visually examine the containment sump to ensure there are no cracks, holes, deteriorated seals, deformation or other
indications that the sump is not liquid tight.
3. If the sump appears to be liquid tight and no water was in the sump, the inspection result is "pass" and no further
action is required.
4. If the sump appears to be liquid tight but water was present within the sump, the inspection result is "fail".
5. If there is visual evidence that the sump is not liquid tight, then repair or replacement (see note below) of the sump is
required.
Inspection Results for the Year 2024
Sump ID
(product stored for STP or
dispenser number)
Sump lid/gasket in good
condition (yes/no)
Sump is dry (yes/no)
All penetration fittings in
good condition (yes/no)
Sump walls/bottom in
good condition (yes/no)
Are there any leaks from
pipe components (yes/no)
Inspection Result
(Pass/Fail)
STP:1 RUL - 1
Y
Y
Y
Y
N
Pass
STP:2 PREMIUM - 1
Y
Y
Y
Y
N
Pass
STP:3 Low Sulfur Diesel -
1
Y
Y
Y
Y
N
Pass
STP:4 E-FREE REG -
CONV(E0) - 1
Y
Y
Y
Y
N
Pass
Comments:

WO: 2372539
Site Diagram
(This site diagram is for reference only and is not drawn to scale)

Work Order:2372539
Site ID / Name:161 / Jackson Foods #161
Address:1567 S. Creek Meadow Rd.
City:Riverton State:UT Zip:84065