DERR-2024-012118

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 30 Owner: Smith’s Food and Drug Centers, Inc.
Address: 4275 South Harrison Boulevard Address: P.O. Box 305103
City, State, Zip: Ogden, Utah 84401 City, State, Zip: Nashville, Tennessee 37230
Facility I.D.#: 1200584 Phone #: [phone]
Testing Company: Westech Phone #: [phone] Date: 9/24/24
This data sheet is for inspecting automatic shutoff devices and ball float valve. See PEI/RP1200 Section 7 for inspection procedures.
Product Grade PUL
Tank Number 2
Tank Volume, gallons 7,796
Tank Diameter, inches 91.63
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:
*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 Taber DeHart, UT-0394 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]

CONTAINMENT SUMP INTEGRITY TESTING
HYDROSTATIC TESTING METHOD
Facility Name: Smith’s 30 Owner: Smith’s Food and Drug Centers, Inc.
Address: 4275 South Harrison Boulevard Address: P.O. Box 305103
City, State, Zip: Ogden, Utah 84401 City, State, Zip: Nashville, Tennessee 37230
Facility I.D.#: 1200584 Phone #: [phone]
Testing Company: Westech Phone #: [phone] Date: 9/24/24
This procedure is to test the leak integrity of containment sumps. See PEI/RP1200 Section 6.5 for the inspection procedure.
Containment Sump ID PUL STP
Containment Sump Material FRP
Liquid and debris removed from sump?* ☒Yes ☐No ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No
Visual Inspection (No cracks, loose parts or separation of
the containment sump.) ☒Yes ☐No ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No
Containment Sump Depth 42”
Height From Bottom to Top of Highest Penetration 8”
Starting Water Level 14 3/16”
Test Start Time 10:27
Ending Water Level 14 3/16”
Test End Time 11:27
Test Period (Minimum test time: 1 hour) 1 hour
Water Level change 0
Pass/fail Criteria: Must pass visual inspection. Water level drop of less than 1/8 inch.
Test Results ☒Pass ☐Fail ☐Pass ☐Fail ☐Pass ☐Fail ☐Pass ☐Fail
Comments:
*All Liquids and debris must be disposed of properly.
Tester’s Name Taber DeHart, UT-0394 Tester’s Signature