DERR-2024-011152

Annual Sump Inspection
IMPACT VALVE
LEAK DETECTOR
Line Tightness Test
MONITOR CERTIFICATION
SPILL BUCKET TEST
STAGE I SURVEY
11000 N. MoPac Expressway, Suite 500
Austin, Texas 78759
Phone: [phone]
Fax: [phone] Date Printed and Mailed: 9/26/2024
UTAH DEPARTMENT OF ENV. QUALITY
UST
PO Box 144840
SALT LAKE CITY, UT 84114
Test Date: 9/23/2024
Order Number: 2371454
Dear Regulator,
Enclosed are the results of recent testing performed at the following facility:
WAL-MART #1572 (WM1572)
1851 W HIGHWAY 40
VERNAL, UT 84078
Testing performed:
Sincerely,
Dawn Kohlmeyer
Manager, Field Reporting
Product Line Tightness Test Page 1 of 1
Work Order: 2371454 Date: 9/23/2024
Site Name/ID: WAL-MART #1572 / WM1572
Address: 1851 W HIGHWAY 40
City: VERNAL State: UT Zip: 84078
Tank Information
Test Method
Customer Tank ID
Product Name
Delivery Type
Test Pressure (psi)
Test Start Time
Test End Time
Final Leak Rate (gph)
Test Result(P/F/I)
Test was performed per
3rd party certifications as
specified in 40 CFR parts
280 and 281
Tank # 1
Line # 1
TLD-1
T1 Regular
UNLEADED
Pressure
60
00:11
01:11
0.00
Pass
Yes
Tank # 1
Line # 2
TLD-1
T1 Regular
UNLEADED
Pressure
60
11:00
12:00
0.00
Pass
Yes
Tank # 2
Line # 1
TLD-1
T2 Premium
PREMIUM
Pressure
60
11:00
12:00
0.00
Pass
Yes
Tank # 2
Line # 2
TLD-1
T2 Premium
PREMIUM
Pressure
60
11:00
12:00
0.00
Pass
Yes
Tank # 3
Line # 1
TLD-1
T3 Diesel
Low Sulfur
Diesel
Pressure
60
11:00
12:00
0.00
Pass
Yes
Tank #
Line #

Technician Comments: ut151
Technician Name:David Mathie Certification #:41442 exp:
10/20/2025
Technician Signature:

Environmental Compliance for Petroleum Systems
©2024 Tanknology Inc., Austin, TX. All rights reserved. tanknology.com
WAL-MART #1572
1851 W HIGHWAY 40
VERNAL UT 84078
WM1572
Tanknology, Inc.
WALMART/SAM'S CLUB
DEPT. 9641 2101 SE Simple Savings Dr.
BENTONVILLE AR 72716
479-360-2779
09/23/2024
UNLEADED PREMIUM
Veeder Root
FX1V
Veeder Root
FX1V
Veeder Root
FX1DV
38
20
150
3
10
4
33
20
150
3
10
4
32
20
130
2
10
3
ut151
David Mathie
NW1-2371454
Low Sulfur Diesel
TT1 Regular:1 TT2 Premium:1 TT3 Diesel:1
Impact Valve
Inspection
Impact Valve Operational
Inspection
Work Order:2371454 Date:9/23/2024
Site Name/ID:WAL-MART #1572
Address:1851 W HIGHWAY 40
City:VERNAL State:UT Zip:84078
How Inspected: Line Test NFPA 30A PEI RP1200 Other
Dispenser
Number Grade
Secure
Mount?
Valve
Lock?Pass/ Fail Comments
1/2 40 Pass Fail Not Tested
1/2 85 Pass Fail Not Tested
1/2 91 Pass Fail Not Tested
3/4 85 Pass Fail Not Tested
3/4 91 Pass Fail Not Tested
5/6 85 Pass Fail Not Tested
5/6 91 Pass Fail Not Tested
7/8 85 Pass Fail Not Tested
7/8 91 Pass Fail Not Tested
9/10 85 Pass Fail Not Tested
9/10 91 Pass Fail Not Tested
11/12 40 Pass Fail Not Tested
11/12 85 Pass Fail Not Tested
11/12 91 Pass Fail Not Tested

Technician Comments:
Technician Name:David Mathie
Signature:
Environmental Compliance for Petroleum Systems
©2024 Tanknology Inc., Austin, TX. All rights reserved. tanknology.com
WAL-MART #1572 WALMART/SAM'S CLUB
1851 W HIGHWAY 40
VERNAL UT 84078
WM1572
Tanknology, Inc.
DEPT. 9641 2101 SE Simple Savings Dr.
BENTONVILLE AR 72716
479-360-2779
800-964-1250 09/23/2024
1 2 3
RUL PREM DSL
VR450PLUS VR450PLUS VR450PLUS
19782 11904 7901
118.4 118..4 118.4
UT151
David Mathie
1851 W HIGHWAY 40
WAL-MART #1572
1851 W HIGHWAY 40, VERNAL, UT 84078
WM1572
Tanknology, Inc.
WALMART/SAM'S CLUB
DEPT. 9641 2101 SE Simple Savings Dr.
BENTONVILLE, AR 72716
479-360-2779
09/23/2024
ANNULAR ANNULAR STP STP STP UDC UDC
RUL PREM/DSL RUL PREM DSL 1/2 3/4
UT151
David Mathie
1851 W HIGHWAY 40
WAL-MART #1572
1851 W HIGHWAY 40, VERNAL, UT 84078
WM1572
Tanknology, Inc.
WALMART/SAM'S CLUB
DEPT. 9641 2101 SE Simple Savings Dr.
BENTONVILLE, AR 72716
479-360-2779
09/23/2024
UDC UDC UDC UDC
5/6 7/8 9/10 11/12
UT151
David Mathie
WAL-MART #1572
1851 W HIGHWAY 40
VERNAL, UT 84078
WM1572
Tanknology, Inc.
WALMART/SAM'S CLUB
479-360-2779
09/23/2024
DEPT. 9641 2101 SE Simple Savings Dr.
BENTONVILLE, AR 72716
1
RUL
5
OPW
2
PREM
5
OPW
3
DSL
5
OPW
15WC
1044
14WC
1049
5 MIN
1
15WC
1051
14WC
1056
5MIN
1
1058
15WC
1103
15WC
5MIN
0
UT151
David Mathie
Stage I Vapor System Survey
Survey to determine compliance with Requirements of Title 40 Part 63 National Emission Standards for Hazardous Air Pollutants for Source Categories

Survey Date 9/23/2024 Work Order 2371454
Cust Name / Location Number WM1572
Street Address 1851 W HIGHWAY 40
City, State, ZipCode VERNAL UT 84078

Product
Stage I Type
Drop Tubes Type
Drop Tubes Max inches from tank Bottom
Fill Adapters Type
Vapor Adapters Type
NESHAP Work Required?

Vent Caps
Type
Labeled Positive Cracking Pressure
Labeled Negative Cracking Pressure
T1 Regular
UNLEADED
Dual Point
Straight w/ Flapper
5.75
Swivel
Swivel (poppet)
No

GAS
Pressure Vacuum cap
3
8
T2 Premium
PREMIUM
Dual Point
Straight w/ Flapper
5.75
Swivel
Swivel (poppet)
No

Describe Work Required

Surveyed by Signature
ANNUAL CONTAINMENT SUMP INSPECTION
This form may be utilized to document the inspection of containment sumps.
Date of Inspection
9/23/2024
UST Facility Person Conducting Test
Facility Name
WAL-MART #1572
Facility ID #
WM1572
Tester's Name
DMATHIE
Physical Address
1851 W HIGHWAY 40
Company
Tanknology Inc.
City
VERNAL
County
UINTAH
State
UT
Certification #
41442
Expiration Date
10/20/2025
UST Owner
WALMART/SAM'S CLUB
Tester's Signature Date
9/23/2024
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:T1 Regular
UNLEADED - 1
Y
Y
Y
Y
N
Pass
STP:T2 Premium
PREMIUM - 1
Y
Y
Y
Y
N
Pass
STP:T3 Diesel Low Sulfur
Diesel - 1
Y
Y
Y
Y
N
Pass

Comments:

WO: 2371454
Site Diagram
(This site diagram is for reference only and is not drawn to scale)

Work Order:2371454
Site ID / Name:WM1572 / WAL-MART #1572
Address:1851 W HIGHWAY 40
City:VERNAL State:UT Zip:84078