HomeMy WebLinkAboutDERR-2024-012113UST Annual Compliance Inspection
Facility Information
Name:Fast Stop 1104 Certification/Inspection #:54946
Address:4795 S 3500 W, Roy, UT, 84067 State ID:1200425
Phone Number:Form Completed By:Larry Vasquez Date:09/30/2024
Tank Information
State Tank ID T3 DSL T4 ETH 88 T2 PUL T1 RUL
Facility Tank # or ID (designation used by facility)T3 DSL T4 EHT 88 T2 PUL T1 RUL
Tank Capacity 4706 gal 4706 gal 4706 gal 14881 gal
Product Name (describe in comments if not listed)Diesel Ethanol Free
Unleaded
Premium Unleaded
Compartment Only (mark only if NOT the entire tank)
Manifolded Tank (mark for true siphon manifold ONLY)
Tank Status*
if Tank Status = TC:IU IU IU IU
Date in TC (assessment & OPS extension required > 1yr)
Emptied to 1" or less? (release detection required if not)Y N
NA
Y N
NA
Y N
NA
Y N
NA
Date emptied to 1" or less
Tank Release Detection Method*ATG-
Interstitial
Monitoring
ATG-
Interstitial
Monitoring
ATG-
Interstitial
Monitoring
ATG-
Interstitial
Monitoring
Tank Corrosion protection*None None None None
Tank Wall Type*FRP FRP FRP FRP
Tank receives > 25 gallons at a time?Yes No Yes No Yes No Yes No
Spill Bucket? (required where UST receives >25 gallons at a time)Yes No Yes No Yes No Yes No
Spill Bucket Size
Spill Bucket Wall Type*
Overfill Protection? (required where UST receives >25 gallons at a time)Yes No Yes No Yes No Yes No
Overfill Protection Type*External
Overfill Alarm
External
Overfill Alarm
External
Overfill Alarm
External
Overfill Alarm
Piping Corrosion protection*Flex-N/A Flex-N/A Flex-N/A Flex-N/A
Flexible Connection - Tank*None None
Flexible Connection - Dispenser*
Piping Wall Type*DW DW DW DW
Piping Delivery System*Pressure Pressure Pressure Pressure
Line Leak Detector Type (required for PR system)*Mechanical Mechanical Mechanical Mechanical
Piping Release Detection Method*Sump Sensor
Monitoring
Sump Sensor
Monitoring
Sump Sensor
Monitoring
Sump Sensor
Monitoring
STP (Turbine Pump) Containment Sump?Yes Yes Yes Yes
STP Containment Sump Wall Type*SW SW SW SW
UDC (Under-dispenser) Containment Sump?No No No No
UDC Containment Sump Wall Type*NA NA NA NA
Piping Transition Sumps?No No No No
Transition Sump Wall Type*NA NA NA NA
Comments
Inspection Checklist
For each facility, complete the Annual Compliance Inspection Checklist below by answering the questions. If the facility contains more
than 5 tanks or 8 dispensers, additional copies of this form must be completed. Questions are designated as either a mandatory
compliance item(●) or a recommended practice item(®). If an item is identified as mandatory and recommended, further information is
provided in a note following the question. If "No" is the answer for any mandatory compliance item(●) question, an associated entry must
be made in the Return to Compliance Plan with documentation of the date when the issue was brought back into compliance. The State
must approve all compliance plan schedules. If "No" is the answer for a recommended practice item (®), it is strongly suggested that the
deficiency be corrected.
Tank Information
Inspection Item T3 DSL T4 ETH 88 T2 PUL T1 RUL
Fill Equipment
●1 Is there a product tag on the fill riser pipe or are the lids painted in
accordance with a posted product code color chart?
Y Y Y Y
®2 Does the fill cap have adequate clearance between the cap and the manhole
cover?
Y Y Y Y
●3 Does the tank have a drop tube that extends to within 6 inches of the bottom
(if no diffuser is present)?
Y Y Y Y
Spill & Overfill Protection
●4 Is each UST that receives more that 25 gallons of product at any one time
equipped with spill and overfill prevention?
Y Y Y Y
●5 Is the spill bucket free of fuel, water or debris?Y Y Y Y
●6 Is the spill bucket in good condition and free of damage?Y Y Y Y
®7 Does the drain assembly work?NA NA NA NA
●8
Is the tank(s) equipped with an overfill device (e.g. overfill alarm, automatic
shut-off device or ball-float valve) and is the device installed according to
manufacturer's specifications to allow proper functionality?
Y Y Y Y
●9 Is the tank overfill alarm mounted near the fill port where it can be seen or
heard by the delivery person?
Y Y Y Y
Temporary Closure
●10
If the tank is in temporary closure and contains greater that 1 inch of
product, is approved release detection performed and maintained? NOTE:
OPS recommends that a tank in temporary closure be emptied (contains <=
1 inch of fluids).
NA NA NA NA
●11 If the tank is in temporary closure, is corrosion protection maintained?NA NA NA NA
●12
If the tank has been in temporary closure for greater than 3 months, is the
vent line open and has the piping, pumps, manways, and ancillary
equipment been capped and secured?
NA NA NA NA
Vapor Recovery (if Required)
●13 Are the vapor recovery adaptor and cap present and free of damage?NA Y Y Y
®14 Does the vapor cap have adequate clearance between the cap and the
manhole cover to enable hook-up?
NA Y Y Y
®15 Is the vapor cap in good condition with a gasket?NA Y Y Y
®16 Is the vapor recovery lid painted orange?NA Y Y Y
Submersible Turbine Pump (STP) Sump
®17 Are the external and/or internal lids easily removed for inspection?Y Y Y Y
®18 Are the sump lid, gasket and seals present and in good condition?Y Y Y Y
●19 Is the sump free of fuel, water or debris?Y Y Y Y
●20 Is the sump free of cracks, holes, bulges, or other defects?Y Y Y Y
●21
If the system contains secondarily contained piping with release detection
consisting of sump sensors installed in the sump, is the interstice open to the
sump?
Y Y Y Y
●22 Is the sump sensor properly mounted at the bottom of the sump and
operating according to the manufacturer's specifications?
Y Y Y Y
●23
Are penetration fittings and entry boots intact, secure and free of damage?
NOTE: If the sump was installed prior to 8-1-08 and is not used for interstitial
monitoring, this is a recommended item.
Y Y Y Y
®24 Are junction boxes sealed and free of corrosion?Y Y Y Y
●25 Are the STP components, piping and flex connectors free of leaks or seeps?Y Y Y Y
●26 If no sump is present, are metal components that are in contact with the soil
cathodically protected?
Y Y Y Y
●27 Are piping and flexible connectors installed according to the manufacturer's
specifications (not kinked or twisted)?
Y Y Y Y
●28
Did the mechanical and/or electronic line-leak detector pass its annual
functionality test which includes a leak simulated in the line as part of the
functionality test?
Y Y Y Y
®29 Is the mechanical leak detector properly vented? (vent tube not kinked or
twisted)
Y Y Y Y
ATG Port
®30 Is the manhole cover in good condition and is there adequate clearance
between the ATG probe cap and the manhole cover?
Y Y Y Y
®31 Is the cap in good condition and does it seal tightly?Y Y Y Y
®32 Are the probe wiring hole, electrical junction box and conduit sealed and in
good condition?
Y Y Y Y
●33 Are the probe, floats, and water/product warning alarms operating according
to the manufacturer's specifications?
Y Y Y Y
ATG Console
●34 Does the ATG console have power?Y Y Y Y
●35 Have all ATG leak alarms been properly addressed?Y Y Y Y
●36
Is the console programmed correctly for the tanks found at the site (e.g.
product, capacity, points, overfill alarm, in-tank test, line-leak detector test,
etc.)?
Y Y Y Y
●37 Is the sump sensor properly mounted at the bottom of the sump?Y Y Y Y
●38 Are the sensors functioning according to the manufacturer's specifications?Y Y Y Y
Tank Interstice
●39 Are the interstitial sensors placed correctly in the tanks?Y Y Y Y
●40 Are the interstitial sensors functioning according to the manufacturer's
specifications?
Y Y Y Y
Cathodic Protection
●41
Are all system components that routinely contain product (tanks, lines, and
other metal components) and that are in contact with the soil properly
cathodically protected?
NA NA NA NA
●42
Has your cathodic protection system (galvanic anodes or impressed current)
been tested within 6 months of installation/repair, and every 3 years
thereafter?
NA NA NA NA
●43 Has the impressed current system (rectifier) been inspected for proper
operation at least every 60 days?
NA NA NA NA
●44
If you have an internally-lined tank without additional cathodic protection,
has it passed and internal inspection within 10 years after installation of the
lining and every 5 years thereafter?
NA NA NA NA
®45 If the system is equipped with impressed current, there are no damaged,
frayed or exposed wires?
NA NA NA NA
Vent Piping
®46 Is the vent cap present and is it the correct type?Y Y Y Y
●47 Is the vent piping of correct height and above obstructions?Y Y Y Y
●48 Are diesel and gasoline tanks vented with separate piping?Y Y Y Y
Unattended Fueling
●49
Is one or more clearly identified emergency shutoff devices located not less
than 20 ft. or more than 100 ft. from the dispensing devices, readily
accessible to patrons?
Y Y Y Y
6
●50 Is a working telephone or other approved, clearly identified means to notify
the fire department provided on the site, and readily accessible to patrons?
Y Y Y Y
●51
Is a fire extinguisher with a minimum rating of 40-B, a maintenance
inspection not older than 1 year, and located no more than a 30 ft, travel
distance from the dispensing devices, readily accessible to patrons?
N N N N
Monthly Inspection
●52 Have all Monthly inspections been performed and documented, and have all
deficiencies noted during the inspections been corrected?
Y Y Y Y
Dispenser Information
Inspection item D1 D2 D3 D4 D5 D6
●53 Is hanging hardware free of visible signs of leakage or damage?Y Y Y Y Y Y
●54 Are all components of hanging hardware of the proper type and size?Y Y Y Y Y Y
●55 If applicable, is fuel product, safety, octane, diesel sulfur, ethanol, signage present and correct?Y Y Y Y Y Y
●56 Is the under-dispenser containment(UDC) sump free of fuel, water or debris?Y Y Y Y Y Y
●57 Is the UDC sump free of cracks, holes, bulges, or other defects?Y Y Y Y Y Y
®58 Are penetration fillings and entry boots intact, secure and free of damage? NOTE: If the sump was
installed prior to 8-1-2008 and is not used for interstitial monitoring, this is a recommended item.
Y Y Y Y Y Y
●59 If the system contains secondarily contained piping with release detection consisting of sump sensors
installed in the sump, is the interstice open to the sump?
Y Y Y Y Y Y
●60 Is the sump sensor properly mounted at the bottom of the sump?Y Y Y Y Y Y
●61 Are junction boxes sealed and free of corrosion?Y Y Y Y Y Y
●62 Are meters, piping and flexible connectors free of leaks or seeps?Y Y Y Y Y Y
●63 Are piping and flexible connectors installed according to the manufacturer's specification? (not kinked
or twisted)
Y Y Y Y Y Y
●64 If no UDC, are any metal piping components in contact with the soil properly cathodically protected?Y Y Y Y Y Y
●65 Are the shear valves operating according to the manufacturer's specifications?Y Y Y Y Y Y
●66 Is at least one fire extinguisher with a minimum rating of 40-B, and a maintenance inspection not older
than 1 year, located within 100 feet of each dispenser and tank fill opening?
Y Y Y Y Y Y
●67 Is an emergency stop button present and operable?Y Y Y Y Y Y
Note:
Deficiency Information
Rec Item Item ID Equip ID Description Remedy Date Image
®51 T1 RUL Fire Extinguisher Not Within 30 Feet and Doesn't
have access to predestines.
®51 T2 PUL Fire Extinguisher Not Within 30 Feet and Doesn't
have access to predestines.
®51 T4 ETH 88 Fire Extinguisher Not Within 30 Feet and Doesn't
have access to predestines.
®51 T3 DSL Fire Extinguisher Not Within 30 Feet and Doesn't
have access to predestines.
Operator Certification
By signing below, the operator certifies that the answers above are accurate and based upon performance of associated inspection
activities, and that the facility owner has received a copy of this inspection form.
Contractor Printed Name:Larry Vasquez Contractor Company Name:CGRS, Inc.
Certification Number:
Contractor Signature:
A or B Operator Printed Name:A or B Operator Cert. No.:
A or B Operator Signature:Date:09/30/2024
AST Annual Compliance Inspection
Facility Information
Name:Fast Stop 1104 Certification/Inspection #:54947
Address:4795 S 3500 W, Roy, UT, 84067 State ID:1200425
Phone Number:Form Completed By:Larry Vasquez Date:09/30/2024
Tank Information
State Tank ID T5 ETH 91
Facility Tank # or ID (designation used by facility)
Tank Capacity 1000 gal
Product Name (describe in comments if not listed)Ethanol Free
Unleaded
Compartment Only (mark only if NOT the entire tank)
Item#T5 ETH 91
Containment
●1 Is the containment structure in satisfactory condition (diking, impounding, double-wall tank, etc)?Y
●2 Are the drainage pipes/valves in good working condition for continued service?Y
Tank Foundation/Supports
®3 Free of tank settlement or foundation washout?Y
●4 Concrete pad or ring wall free of cracking or spalling?Y
●5 Tank supports in satisfactory condition?Y
●6 Is water able to drain away from tank?Y
●7 Is the grounding strap between the tank and foundation/supports in good condition?Y
Cathodic Protection
®8 Are cathodic protection system in operating condition and functional?NA
●9 Rectifier readings: Volts
●10 Rectifier readings: Amps
●11 Are these readings within manufacturer specifications?NA
Tank External Coating
●12 Tank shell/head free of visible signs of paint failure?Y
Tank Shell/Heads
●13 Tank shell/head free of noticeable distortions, buckling, denting or buldging?Y
●14 Tank shell/head free of visible signs of corrosion or cracking?Y
Tank Manways,Piping and Equipment
®15 Is aboveground piping free of leaks?Y
®16 Are required valves present?Y
®17 Are valves,installed correctly, operating correctly, free of damage,and free of leaks?Y
®18 Are the spill containment boxes on the fill pipes free of damage, or wear that compromise the integrity of the unit Y
®19 If no sump is present, are metal components that are in contact with the soil cathodically protected?NA
●20 Did the mechanical and/or electronic line-leak detector pass its annual functionality test which includes a leak simulated
in the line as part of the functionality test?
Y
●21 Is the mechanical leak detector properly vented? (vent tube not kinked or twisted)Y
Tank Roof
●22 Roof is free of standing water?Y
●23 Roof is free of visible signs of coating cracking, crazing, peeling or blistering?Y
●24 Roof is free of holes?Y
Venting
®25 Normal and emergency vents free of obstructions?Y
●26 Normal vent on tanks storing gasoline equipped with pressure/vacuum vent cap?Y
●27 Is the emergency vent in good working condition and functional, and tested as required by manufacturer?Y
Insulated Tanks
●28 Free of missing insulation?Y
●29 Insulation free of noticeable areas of moisture?Y
®30 Insulation free of mold?Y
®31 Insulation free of visible signs of damage?Y
®32 Insulation adequately protected from water intrusion?Y
Level and overfill Prevention Equipment
®33 Electronic or mechanical liquid level gauge tested for proper operation?Y
●34 Electronic or mechanical liquid level gauge calibrated during the previous 12 months?Y
●35 Is overfill prevention equipment in good working condition?Y
●36 Overfill prevention equipment type:Audible Alarm
●37 Overfill prevention equipment operational and in good condition?Y
●38 Is tank ullage being determined and documented before filling the tank?Y
Electrical Equipment
●39 Is electrical equipment grounding adequate and in good condition?Y
●40 Is electrical wiring for control boxes, lights, and other high voltage equipment in good condition?Y
Tank/Piping Release Detection
●41 Is inventory control being performed and documented as required?Y
●42 Is release detection being performed and documented on underground piping as required?Y
Tank Interstice
●43 Is interstice free of liquid?NA
●44 Is interstitial monitoring equipment in good working condition?NA
Item#Piping Containment Sump T5 ETH 91
●45 Is the sump free of fuel, water or debris Y
●46 Is the sump free of cracks, holes, buldges, or other defects?Y
®47 Are penetration fittings and entry boots intact, secure and free of damage?Y
●48 If the system contains secondarily contained piping with release detection consisting of sump sensors installed in the
sump, is the interstice open to the sump?
Y
●49 Is the sump sensor properly mounted at the bottom of the sump?Y
●50 Are juction boxes sealed and free of corrosion?Y
1Qty:Dispenser
Item#
●51 Is hanging hardware free of visible signs of leakage or damage?Y
●52 Are all components of hanging hardware of the proper type and size?Y
●53 If applicable, is fuel product, safety, octane, diesel sulfer, ethanol, signage present and correct?Y
●54 Are meters, piping, and flexible connectors free of leaks or seeps?Y
●55 Are piping and flexible connectors installed according to manufacturer's specifications? (not kinked or twisted)Y
®56 If no UDC, are any metalpiping components in contact with the soil properly cathodically protected?Y
●57 Are shear valves operating according to the manufacturer's specifications?Y
Item#Site Inspection
●58 Is one or more clearly identified emergency shutoff devices located not less than 20ft nor more than 100ft from the dispensing devices,
readily accessible to patrons?
N
●59 Are the required additional operating and emergency instructions posted and clearly readable in the dispensing area?Y
●60 Is a fire extinguisher with a minimum rating of 40-B, a maintenance inspection not older than 1 year, and located no more than 30ft travel
distance from the dispensing devices, readily accessible to patrons?
Y
●61 Is a working telephone or other approved, clearly identifed means to notify the fire department provided on the site, and readily accessible to
patrons?
Y
Additional Comments:
Notes:
Deficiency Information
Rec Item Item ID Equip ID Description Remedy Date Image
®58 T5 ETH 91 Fire extinguisher not close to Disp 11/12
Inspector Information
By signing below, the operator certifies that the answers above are accurate and based upon performance of associated inspection activities, and that
the facility owner has received a copy of this inspection form.
Contractor Signature:Date:09/30/2024
Printed Name:Larry Vasquez Certification Number:
Automatic Tank Gauge Inspection
ATG 1
ATG 1654
Facility Information
Name:Fast Stop 1104 Certification/Inspection #:54950
Address:4795 S 3500 W, Roy, UT, 84067 State ID:1200425
Phone Number:Form Completed By:Larry Vasquez Date:09/30/2024
ATG Console Inspection
Tank Level Monitor Brand :Veeder Root
1.Status upon Arrival:All Functions Normal
2.Status upon Departure:All Functions Normal
3.Is the display in good
condition and functioning?:
Yes
4.Is the keypad in good
condition?:
Yes
Tank Level Monitor Model :TLS-450
5.Are all indicator lights
functional?:
Yes
6.Is printer functional?:Yes
7.Back-up battery tested? (if
applicable)?:
Yes
8.Back-up battery voltage (if
applicable):
Tank Information
Probe and Programing Inspection:
9.Tank # T1 RUL T2 PUL T5 ETH 91 T3 DSL T4 ETH 88
10.Tank Facility ID T1 RUL T2 PUL T5 ETH 91 T3 DSL T4 EHT 88
11.Tank # per ATG T1 Rul T2 Pul T5 ETH T3 DSL T4 EHT
12.Product:Unleaded Premium Ethanol Free
Unleaded Diesel Ethanol Free
Unleaded
13.Tank Volume, gallons 14881 4706 1000 4706 4706
14.Tank Dia/depth, inches 90.5 90.5 90.5 90.5
In-Tank Setup Parameters:
15.Thermal coefficient 0.000700 0.000700 0.000700 0.000450 0.000700
16.ATG Programmed Diameter 90.5 90.5 36 90.5 90.5
17.Number of points on profile
18.Full volume on profile 14881 4706 1000 4706 4706
Pass/Fail Criteria: if any of questions 19, 20 ,21 & 22 are No, then the system has failed the test.
Comment
Operator Certification
Contractor Signature:Printed Name:Larry Vasquez
19.After removing the probe from the tank, it has been
inspected and any damaged or missing parts replaced?
Yes Yes Yes Yes Yes
20.Do floats move freely along the stem without binding?Yes Yes Yes Yes Yes
21.Does product level match console value?Yes Yes Yes Yes Yes
22.Does water level match console value?Yes Yes Yes Yes Yes
23.Water warning (inches)(1")1.5 1.5 1.5 1.5 1.5
24.High water limit (inches)(1.5")2.5 2.5 2.5 2.5 2.5
25.Does console water alarm trigger at programmed level?Yes Yes Yes Yes Yes
26.Programmed Overfill Limit (90%)90 90 90 90 90
27.Does console overfill alarm trigger at programmed level?Yes Yes Yes Yes Yes
28.Programmed High Product Limit (95%)95 95 95 95 95
29.Does console high product alarm trigger at programmed
level?
Yes Yes Yes Yes Yes
30.Low Product (15% of tank volume or 15" whichever is
greater)15 15 15 15 15
31.Tank test program enabled?Yes Yes Yes Yes Yes
32.Tank Test Method?CSLD CSLD CSLD CSLD CSLD
33.Tank Test Rate 0.2 0.2 0.2 0.2 0.2
34.Test duration (hrs)12 12 12 12 12
35.12 months of tank test history present?Yes Yes Yes Yes Yes
Lines:
36.Electronic Line Leak Type NA NA NA NA NA
37.Line # and label in ATG (Q1, Unleaded)N/A N/A N/A N/A N/A
38.Line Test Rate N/A N/A N/A N/A N/A
39.12 months of line test history present?NA NA NA NA NA
40.Test Result Pass Pass Pass Pass Pass
Leak Detector
Facility Information
Name:Fast Stop 1104 Certification/Inspection #:54943
Address:4795 S 3500 W, Roy, UT, 84067 State ID:1200425
Phone Number:Form Completed By:Larry Vasquez Date:09/30/2024
Tank Information
Tank #:T1 RUL T2 PUL T3 DSL T4 ETH 88 T5 ETH 91
Capacity:14881 4706 4706 4706 1000
Product:Unleaded Premium Diesel Ethanol Free
Unleaded
Ethanol Free
Unleaded
Line #:RUL PUL DSL EHT 99
Line Type:Pressure Pressure Pressure Pressure
LD Brand:VMI VMI VMI VMI
LD Model:LD-2000 LD-2000 LD-2000 LD-2000
Serial #:0 0 0 0
Associated Tank:T1 RUL T2 PUL T3 DSL T4 ETH 88
Resiliency (ml):100 90 100 90
Check Valve Holding PSI:20 19 27 24
Opening Time:2 2 2 2
Result:Pass Pass Pass Pass
Test Equip. Mfg.:Vaporless, LDT-890 Vaporless, LDT-890 Vaporless, LDT-890 Vaporless, LDT-890
Notes:
Tested per manufacturer specifications.
Contractor Signature:Printed Name:Larry Vasquez
Line Test
Facility Information
Name:Fast Stop 1104 Certification/Inspection #:54942
Address:4795 S 3500 W State ID:1200425
Phone Number:Form Completed By:Larry Vasquez Date:09/30/2024
Tank Test Information
Tank #:T1 RUL T2 PUL T3 DSL T4 ETH 88 T5 ETH 91
Capacity:14881 4706 4706 4706 1000
Product:Unleaded Premium Diesel Ethanol Free
Unleaded
Ethanol Free
Unleaded
Line Test Information
Line #:RUL PUL DSL EHT 99 ETH 91
LineType:Pressure Pressure Pressure Pressure Pressure
Line Material:DW Flex DW Flex DW Flex DW Flex DW Flex
Line ID Size (in):2 2 2 2 2
Line Length (ft):300 300 300 300 100
Pump Type:Red Jacket Red Jacket Red Jacket Red Jacket Red Jacket
Associated Tank:T1 RUL T2 PUL T3 DSL T4 ETH 88 T5 ETH 91
Test Equip. Mfg.:Triangle Triangle Triangle Triangle Triangle
Test Pressure (PSI):50 50 50 50 50
Initial Cyl. Level:100 100 350 360 360
Final Cyl. Level:70 70 340 360 360
Change in Time (mins):15 15 15 15 15
Change in Vol:-30.0000 -30.0000 -10.0000 0.0000 0.0000
Change in Temp (F):0 0 0 0 0
Coeff. Of Thermal Expansion (g/F):0.00700 0.00070 0.00045 0.00070 0.00070
Line Vol (gal):48.94 48.94 48.94 48.94 16.31
Leak Rate (GPH):-0.0317 -0.0317 -0.0106 0.0000 0.0000
Result:Pass Pass Pass Pass Pass
Notes
TIGHTNESS TESTING CERTIFICATION
CGRS certifies that the systems in the above table have been tested utilizing leak detection methods which meet the prescribed leak rate testing
standard of 0.10 gph with a minimum probability of detection of 95% and a 5% probability of a false alarm. CGRS further certifies that the protocol for
each test method was strictly adhered to, and that all precision tightness testing performed by CGRS was conducted in accordance with EPA 40 CFR
parts 280.43(c) and 280.44(b) and the National Fire Protection Association, Bulletin NFPA 329 criteria.
Contractor Printed Name:Larry Vasquez Contractor Signature:
Certification Number:TMI-301
UST Operator Inspection -Utah
YEAR Qo ~'f
~ Facility Name hid Sh: IID Lj .Inc, Facility ID f 2.oo i./-2S'
0 1\u u+ ?i L/n '1 '1 jPrlmary Class B Operator
Address lf 11fJ S . 1 5 00 /J .
NAME(S) AND INITIALS OF PERSON(S) CONDUCTIN a'MONTHLY INSPECTIONS:
J ~,CA. f3 ,-.,,P ~ }Zo )7i"'-ttz;i r& is-k,,-, /l(r-t Su,• .. ~~
Please respond to ALL of the following questions with a V (Yes), N (No), or NA (Not Applicable) answer .
Months of the Current Year J F M A M J J A s 0 N D
Monthly Inspection -Release Detection
1 Rel e ase detection equipment is operati ng with no alarms or other unusual
'1 ·-1 y ✓ y 'I y V operating conditions. '( ~
2 Records of release detection (tanks and pipi ng) are reviewed and current. 'I 'i 'J \/ '( ✓ V ,/ y V
Monthly Inspection -Spill Prevention Equipment ' .
3 Equ i pment is undamaged, intact and free from defects. " ~ " " y v V 'I y
4 Equipment is free from debris, water, or product. \/ "' \J " .-t ../ V I/
V y V
5 Fill Pipe i s unobstructed. '( 'i y v 'v ' V 'l " V
6 Fill cap is un-broken and is securely on the fill pipe. " 'I 'I 'i y V I/ I/ V
7 Double walled spill prevention equipment -Interstitial area is free from leaks. "i '{ "{ 'I y ✓ '"~ ,.,,Jn y
Initials of person performing Inspection. et\ ~ ti-I i ,t ~ ~ Ah 1/l lt U/ I&-.,-,, '"
Annual Inspection -Containment Sumps Date of annual lnspec11on
8 Secondary Containment Sumps Visual Inspection of sump indicates no damage and it is free from debris, wat er and fuel. 9
(STP, Dispenser and Transition) The penetrat ion fittings for conduits and piping entering the STP Sumps are intact. y
~~ 9 Double Walled Sumps Interstitial area is free from leaks. y ~, Hand-held release detection Hand-held release detection equipment (bailer, gauge stick, etc.) is serviceable and y -10 equipment operable.
I certify under penalty of law that I am the Class B Operator referenced above and that I am familiar with information on this form
and that it is true, accurate and was completed in accordance with R311-203-7 . / .,
Si gnature of the Primary Class B Operator (Sign this document after the last inspection of the Current Year) Da~lf
B Operator#
Comments/Follow u!:
Turn ove r for r ecord of Jnterslllia l Monitoring visu al insp ections a nd Impres sed Curre nt r ec tifier chec k s.
1 -
y
pei.org 57
Recommended Practices for the Testing and Verification of Spill, Overfill, Leak Detection and Secondary Containment Equipment at UST Facilities
APPENDIX C-7
AUTOMATIC TANK GAUGE
OPERATION INSPECTION
Facility Name:Owner:
Address:Address:
City, State, Zip Code:City, State, Zip Code:
Facility I.D. #:Phone #:
Testing Company:Phone #:Date:
This procedure is to determine whether the automatic tank guage (ATG) is operating properly. See PEI/RP1200 Section 8.2 for the
inspection procedure. This procedure is applicable to tank level monitor stems that touch the bottom of the tank when in place.
Tank Number
Product Stored
ATG Brand and Model
1. Tank Volume, gallons
2. Tank Diameter, inches
3. After removing the ATG from the tank, it has
been inspected and any damaged or missing
parts replaced?
Yes No Yes No Yes No Yes No
4. Float moves freely on the stem without
binding? Yes No Yes No Yes No Yes No
5. Fuel float level agrees with the value pro-
grammed into the console? Yes No Yes No Yes No Yes No
6. Water float level agrees with the value pro-
grammed into the console? Yes No Yes No Yes No Yes No
7.Inch level from bottom of stem when 90%
alarm is triggered.
8. Inch level at which the overfill alarm activates
corresponds with value programmed in the
gauge?
Yes No Yes No Yes No Yes No
9. Inch level from the bottom when the water
float first triggers an alarm.
10. Inch level at which the water float alarm acti-
vates corresponds with value programmed in
the gauge?
Yes No Yes No Yes No Yes No
If any answers in Lines 3, 4, 5, or 6 are “No,” the system has failed the test.
Test Results Pass Fail Pass Fail Pass Fail Pass Fail
Comments:
Tester’s Name (print) ___________________________________ Tester’s Signature _________________________________
Fast Stop 1104
4795 S 3500 W,
Roy, UT 84067
1200425
CGRS 9/5/24
T1 T 2 T 3
T4
RUl PUL DSL ETH88
TLS 450 TLS 450 TLS 450 TLS 450
14881 4706 4706 4706
90.5 90.5 90.5 90.5
81.5 81.5 81.5 81.5
2.5 2.5 2.5 2.5
Ray Simms
pei.org 57
Recommended Practices for the Testing and Verification of Spill, Overfill, Leak Detection and Secondary Containment Equipment at UST Facilities
APPENDIX C-7
AUTOMATIC TANK GAUGE
OPERATION INSPECTION
Facility Name:Owner:
Address:Address:
City, State, Zip Code:City, State, Zip Code:
Facility I.D. #:Phone #:
Testing Company:Phone #:Date:
This procedure is to determine whether the automatic tank guage (ATG) is operating properly. See PEI/RP1200 Section 8.2 for the
inspection procedure. This procedure is applicable to tank level monitor stems that touch the bottom of the tank when in place.
Tank Number
Product Stored
ATG Brand and Model
1. Tank Volume, gallons
2. Tank Diameter, inches
3. After removing the ATG from the tank, it has
been inspected and any damaged or missing
parts replaced?
Yes No Yes No Yes No Yes No
4. Float moves freely on the stem without
binding? Yes No Yes No Yes No Yes No
5. Fuel float level agrees with the value pro-
grammed into the console? Yes No Yes No Yes No Yes No
6. Water float level agrees with the value pro-
grammed into the console? Yes No Yes No Yes No Yes No
7.Inch level from bottom of stem when 90%
alarm is triggered.
8. Inch level at which the overfill alarm activates
corresponds with value programmed in the
gauge?
Yes No Yes No Yes No Yes No
9. Inch level from the bottom when the water
float first triggers an alarm.
10. Inch level at which the water float alarm acti-
vates corresponds with value programmed in
the gauge?
Yes No Yes No Yes No Yes No
If any answers in Lines 3, 4, 5, or 6 are “No,” the system has failed the test.
Test Results Pass Fail Pass Fail Pass Fail Pass Fail
Comments:
Tester’s Name (print) ___________________________________ Tester’s Signature _________________________________
Fast Stop 1104
4795 S 3500 W
Roy, UT 84067
1200425
CGRS 9/5/24
T5
ETH 91
TLS 450 TLS 450 TLS 450 TLS 450
1000
36
32.5
2.5
Ray Simms
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LIQUID SENSOR FUNCTIONALITY TESTING
Facility Name:Owner:
Address:Address:
City, State, Zip Code:City, State, Zip Code:
Facility I.D. #:Phone #:
Testing Company:Phone #:Date:
This procedure is to determine whether liquid sensors located in the interstitial space of UST systems are able to detect the presence of water and fuel. See PEI/RP1200
Section 8.3 for the test procedure.
Sensor Location
Product Stored
Type of Sensor
Discriminating
Non-discrimi-
nating
Discriminating
Non-discrimi-
nating
Discriminating
Non-discrimi-
nating
Discriminating
Non-discrimi-
nating
Discriminating
Non-discrimi-
nating
Discriminating
Non-discrimi-
nating
Discriminating
Non-discrimi-
nating
Test Liquid Water
Product
Water
Product
Water
Product
Water
Product
Water
Product
Water
Product
Water
Product
Is the ATG console clear of any active
or recurring warnings or alarms
regarding the leak sensor? If the
sensor is in alarm and functioning,
indicate why.
Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Is the sensor alarm circuit
operational? Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Has sensor been inspected and in
good operating condition? Yes No Yes No Yes No Yes No Yes No Yes No Yes No
When placed in the test liquid, does
the sensor trigger an alarm? Yes No Yes No Yes No Yes No Yes No Yes No Yes No
When an alarm is triggered, is the
sensor properly identified on the ATG
console?
Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Any “No” answers indicates the sensor fails the test.
Test Results Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
Comments:
Tester’s Name (print) ___________________________________ Tester’s Signature _______________________________________________
Fast Stop 1104
4795 S 3500 W,
Roy, UT 84067
1200425
CGRS
DISP 1/2 Disp 2/3 Dsip 4/5 DISp 6/7 DISP 8/9 DISP 10/11 Disp 12/3
PUL RUL PUL RUL PUL RUL PUL RUL PUL RUL DSL, PUL RUL DSL,Pul RUL
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LIQUID SENSOR FUNCTIONALITY TESTING
Facility Name:Owner:
Address:Address:
City, State, Zip Code:City, State, Zip Code:
Facility I.D. #:Phone #:
Testing Company:Phone #:Date:
This procedure is to determine whether liquid sensors located in the interstitial space of UST systems are able to detect the presence of water and fuel. See PEI/RP1200
Section 8.3 for the test procedure.
Sensor Location
Product Stored
Type of Sensor
Discriminating
Non-discrimi-
nating
Discriminating
Non-discrimi-
nating
Discriminating
Non-discrimi-
nating
Discriminating
Non-discrimi-
nating
Discriminating
Non-discrimi-
nating
Discriminating
Non-discrimi-
nating
Discriminating
Non-discrimi-
nating
Test Liquid Water
Product
Water
Product
Water
Product
Water
Product
Water
Product
Water
Product
Water
Product
Is the ATG console clear of any active
or recurring warnings or alarms
regarding the leak sensor? If the
sensor is in alarm and functioning,
indicate why.
Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Is the sensor alarm circuit
operational? Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Has sensor been inspected and in
good operating condition? Yes No Yes No Yes No Yes No Yes No Yes No Yes No
When placed in the test liquid, does
the sensor trigger an alarm? Yes No Yes No Yes No Yes No Yes No Yes No Yes No
When an alarm is triggered, is the
sensor properly identified on the ATG
console?
Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Any “No” answers indicates the sensor fails the test.
Test Results Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
Comments:
Tester’s Name (print) ___________________________________ Tester’s Signature _______________________________________________
Fast Stop 1104
4795 S 3500 W,
Roy, UT 84067
1200425
CGRS 10 -1-24
T1 RUL T2 PUL T3 DSL T4 88 ETH 91 Piping
RUL PUL DSL 88Eth 91 ETH
Larry Vasquez
pei.org 59
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 TESTS
Facility Name:Owner:
Address:Address:
City, State, Zip Code:City, State, Zip Code:
Facility I.D. #:Phone #:
Testing Company:Phone #:Date:
This data sheet can be used to test mechanical line leak detectors (MLLD) and electronic line leak detectors (ELLD) with submersible
turbine pump (STP) systems. See PEI/RP1200 Sections 9.1 and 9.2 for test procedures.
Line Number
Product Stored
Leak Detector Manufacturer
Leak Detector Model
Type of Leak Detector MLLD
ELLD
MLLD
ELLD
MLLD
ELLD
MLLD
ELLD
MLLD
ELLD
MLLD
ELLD
MLLD (ALL PRESSURE MEASUREMENTS ARE MADE IN PSIG)
STP Full Operating Pressure
Check Valve Holding Pressure
Line Resiliency (ml) (line bleed back vol-
ume as measured from check valve hold-
ing pressure to 0 psig)
Step Through Time in Seconds (time the
MLLD hesitates at metering pressure
before going to full operating pressure
as measured from 0 psig with no leak
induced on the line)
Metering Pressure (STP pressure when
simulated leak rate 3 gph at 10 psig)
Opening Time in Seconds (the time the
MLLD opens to allow full pressure after
simulated leak is stopped)
Does the STP pressure remain at or
below the metering pressure for at least
60 seconds when the simulated leak is
induced?
Yes No Yes No Yes No Yes No Yes No Yes No
Does the leak detector reset (trip) when
the line pressure is bled off to zero psig? Yes No Yes No Yes No Yes No Yes No Yes No
Does the STP properly cycle on/off under
normal fuel system operation conditions? Yes No Yes No Yes No Yes No Yes No Yes No
A “No” answer to either of the above questions indicates the MLLD fails the test.
ELLD (ALL PRESSURE MEASUREMENTS ARE MADE IN PSIG)
STP Full Operating Pressure
How many test cycles are observed
before alarm/shutdown occurs?
Does the simulated leak cause an alarm? Yes No Yes No Yes No Yes No Yes No Yes No
A “No” answer to the above question indi-
cates the ELLD fails the test.
Does the simulated leak cause an STP
shutdown?
Yes No
NA
Yes No
NA
Yes No
NA
Yes No
NA
Yes No
NA
Yes No
NA
Test Results Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
Comments:
Tester’s Name (print) ___________________________________ Tester’s Signature __________________________________
Fast Stop 1104
4795 S 3500 W,
Roy, UT 84067
1200425
CGRS 9-30-24
L 1 L 2 L 3 L 4
RUL PUL DSL 88 ETH
VMI VMI VMI VMI
LD-2000 LD-2000 LD-2000 LD-2000
2 5 2 4 2 5 2 7
20 19 27 24
100 90 100 90
2 2 2 2
10 13 15 13
2 2 2 2
UTAH CONTAINMENT SUMP TEST
Hydrostatic Test Form
Tester’s Signature______________________________
Facility Name Facility ID
Address Tester’s Name
Test Date Phone
Type of
containment
Sump
Dispenser
Transition
Tank Top
Dispenser
Transition
Tank Top
Dispenser
Transition
Tank Top
Dispenser
Transition
Tank Top
Dispenser
Transition
Tank Top
Dispenser
Transition
Tank Top
Sump ID
(e.g. dispenser #, tank
location, product, etc.)
Sump Material
Construction Single walled
Double walled
Single walled
Double walled
Single walled
Double walled
Single walled
Double walled
Single walled
Double walled
Single walled
Double walled
Liquid and debris
removed
Yes
No
Yes
No Yes
No Yes
No Yes
No Yes
No
Visual Inspection
No cracks, holes
or separations.
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Containment
Sump Depth
Height from bottom
to top of highest
penetration
Start Level
Start Time
Ending Level
End Time
Test Period
(Minimum of 1 hour)
Water Level
Change
Test Results Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Photos indicating
water levels 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 6.5 Test Method
How was the liquid disposed?
Comments
Aug 2016 I certify under penalty of law that the above information is true, accurate and complete.
Fast Stop 1104 1200425
Roy, UT 84067 9-30-24
T1 RUl T2 PUL T3 DSL T4 88ETH T5 91 ETH
FRP FRP FRP FRP FRP
40"40"40"40"28"
50"50"50"50"32"
22"22"21"22"9"
4:32 7:29 6:19 3:32 12:51
22"22"21"22"9"
5:32 8:29 7:19 4:32 1:51
1 1 1 1 1
0 0 0 0 0
4795 S 3500 W,
UTAH CONTAINMENT SUMP TEST
Hydrostatic Test Form
Tester’s Signature______________________________
Facility Name Facility ID
Address Tester’s Name
Test Date Phone
Type of
containment
Sump
Dispenser
Transition
Tank Top
Dispenser
Transition
Tank Top
Dispenser
Transition
Tank Top
Dispenser
Transition
Tank Top
Dispenser
Transition
Tank Top
Dispenser
Transition
Tank Top
Sump ID
(e.g. dispenser #, tank
location, product, etc.)
Sump Material
Construction Single walled
Double walled
Single walled
Double walled
Single walled
Double walled
Single walled
Double walled
Single walled
Double walled
Single walled
Double walled
Liquid and debris
removed
Yes
No
Yes
No Yes
No Yes
No Yes
No Yes
No
Visual Inspection
No cracks, holes
or separations.
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Containment
Sump Depth
Height from bottom
to top of highest
penetration
Start Level
Start Time
Ending Level
End Time
Test Period
(Minimum of 1 hour)
Water Level
Change
Test Results Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Photos indicating
water levels 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 6.5 Test Method
How was the liquid disposed?
Comments
Aug 2016 I certify under penalty of law that the above information is true, accurate and complete.
Fast Stop 1104 1200425
Roy, UT 84067 9-30-24
1/2 3/4 5/6 7/8 9/10 11/12
Poly Poly Poly Poly Poly poly
28"28"28"28"28"28"
31"31"31"31"31"31"
8"8"10"8"9"9"
9:25 9:41 9:45 9:55 12:51 12:51
8"8"10"8"9"9"
9:25 9:41 9:45 9:55 1:51 1:51
1 1 1 1 1 1
0 0 0 0 0 0
4795 S 3500 W,