DERR-2024-012611

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]

PRODUCT PIPING INTEGRITY TESTING
Facility Name: Intermountain Riverton Hospital Owner: Intermountain Healthcare – Riverton
Address: 3751 West 12600 South Address: 3741 West 12600 South
City, State, Zip: Riverton, Utah 84065 City, State, Zip: Riverton, Utah 84065
Facility I.D.#: 4002411 Phone #: [phone]
Testing Company: Westech Phone #: [phone] Date: 10/9/24
This procedure is to test the integrity of product piping. Tests were performed with Petro-Tite line tester.
Tank Number 1
Product Stored Red DSL
Piping Run Only
Piping Type Flex D/W
Test Pressure (PSI) 50
Test Duration (minutes) 30
Leak Rate (GPH) 0.003
Test Results ☒Pass ☐Fail ☐Pass ☐Fail ☐Pass ☐Fail ☐Pass ☐Fail
Comments:
Tester’s Name Taber DeHart, UT-0394 Tester’s Signature

DSL
Transition Sump
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]

MECHANICAL AND ELECTRONIC LINE LEAK DETECTOR PERFORMANCE TESTS
Facility Name: Intermountain Riverton Hospital Owner: Intermountain Healthcare – Riverton
Address: 3751 West 12600 South Address: 3741 West 12600 South
City, State, Zip: Riverton, Utah 84065 City, State, Zip: Riverton, Utah 84065
Facility I.D.#: 4002411 Phone #: [phone]
Testing Company: Westech Phone #: [phone] Date: 10/9/24
This data sheet can be used to test the mechanical line leak detector (MLLD) and electronic line leak detector (ELLD) with submersible turbine
pump (STP) systems. See PEI/RP 1200 Sections 9.1 and 9.2 for test procedures.
Line Number 1
Product Stored DSL
Leak Detector Manufacturer Veeder Root
Leak Detector Model PLLD
Type Of leak Detector
☐MLLD
☒ELLD
☐MLLD
☐ELLD
☐MLLD
☐ELLD
☐MLLD
☐ELLD
MLLD (ALL PRESSURE MEASURMENTS ARE MADE IN PSIG)
STP full operating pressure
Check valve holding pressure
Line resiliency (ml) (line bleedback volume as measured
from check valve holding 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 sig 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
Does the leak detector reset (trip) when the line pressure is
bled off to zero psig? ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No
Does STP properly clycle on/off under normal fuel system
operating conditions? ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No
A "No" answer to any of the above questions indicates that the MLLD fails the test.
ELLD (ALL PRESSURE MEASURMENTS ARE MADE IN PSIG)
STP full operating pressure 30
How many test cycles are observed before alarm/shutdown
occurs? 2
Does the simulated leak cause on alarm? ☒Yes ☐No ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No
A "No" answer to the above question indicates that the ELLD fails the test.
Does the simulated leak cause an STP shutdown? ☒Yes ☐No ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No
Test Results ☒Pass ☐Fail ☐Pass ☐Fail ☐Pass ☐Fail ☐Pass ☐Fail
Comments:
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]

AUTOMATIC TANK GAUGE OPERATION INSPECTION
Facility Name: Intermountain Riverton Hospital Owner: Intermountain Healthcare – Riverton
Address: 3751 West 12600 South Address: 3741 West 12600 South
City, State, Zip: Riverton, Utah 84065 City, State, Zip: Riverton, Utah 84065
Facility I.D.#: 4002411 Phone #: [phone]
Testing Company: Westech Phone #: [phone] Date: 10/9/24
This procedure is to determine whether the automatic tank gauge (ATG) is operating properly. See PEI/RP1200 Section 8.2 for the inspection
procedure. This procedure is applicable to tank monitor stems the touch the bottom of the tank when in place.
Tank Number 1
Product Stored Red DSL
ATG Brand and Model TLS 350
1. Tank Volume, gallons 30,000
2. Tank Diameter, inches 120
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 agree with the value programmed
into the console? ☒Yes ☐No ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No
6. Water float level agree with the value programmed
into the console? ☒Yes ☐No ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No
7. Inch level from the bottom of the stem when 90%
alarm is triggered? 100 1/4
8. Inch level at which the overfill alarm activates
corresponds with the 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? 1.5
10. Inch level at which the water float alarm activates
corresponds with the 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: Battery OK
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]

LIQUID SENSER FUNCTIONALITY TESTING
Facility Name: Intermountain Riverton Hospital Owner: Intermountain Healthcare – Riverton
Address: 3751 West 12600 South Address: 3741 West 12600 South
City, State, Zip: Riverton, Utah 84065 City, State, Zip: Riverton, Utah 84065
Facility I.D.#: 4002411 Phone #: [phone]
Testing Company: Westech Phone #: [phone] Date: 10/9/24
This procedure is to determine whether liquid sensors, located in the interstitial spaces of the UST systems, are able to det ect the presence of water and fuel. See
PEI/RP1200, Section 8.3 for the test procedure.
Sensor Location L1 (East) L2 (West) L3 (INT) L4 Trans
Product Stored Red DSL Red DSL Red DSL Red DSL
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 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 test liquid, does the
sensor trigger an alarm? ☒ Yes ☐ No ☒ Yes ☐ No ☒ Yes ☐ No ☒ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No
When alarm is trigger, is the sensor
identified on the ATG console? ☒ Yes ☐ No ☒ Yes ☐ No ☒ Yes ☐ No ☒ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No
Any “No” answers indicate 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: 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]

SPILL BUCKET INTEGRITY TESTING HYDROSTATIC TEST METHOD
SINGLE- AND DOUBLE-WALLED VACUUM TEST METHOD
Facility Name: Intermountain Riverton Hospital Owner: Intermountain Healthcare – Riverton
Address: 3751 West 12600 South Address: 3741 West 12600 South
City, State, Zip: Riverton, Utah 84065 City, State, Zip: Riverton, Utah 84065
Facility I.D.#: 4002411 Phone #: [phone]
Testing Company: Westech Phone #: [phone] Date: 10/9/24
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
Product Stored Red DSL
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 15” WC
Test Start Time 0
Ending Level 13” WC
Test End Time 5
Test Period 5-Minute
Level Change 0” WC
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:
*All liquids and debris must be disposed of properly
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]

UST OVERFILL EQUIPMENT INSPECTION
AUTOMATIC SHUTOFF DEVICE AND BALL FLOAT VALVE
Facility Name: Intermountain Riverton Hospital Owner: Intermountain Healthcare – Riverton
Address: 3751 West 12600 South Address: 3741 West 12600 South
City, State, Zip: Riverton, Utah 84065 City, State, Zip: Riverton, Utah 84065
Facility I.D.#: 4002411 Phone #: [phone]
Testing Company: Westech Phone #: [phone] Date: 10/9/24
This data sheet is for inspecting automatic shutoff devices and ball float valve. See PEI/RP1200 Section 7 for inspection pro cedures.
Product Grade Red DSL
Tank Number 1
Tank Volume, gallons 30,000
Tank Diameter, inches 120
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