DERR-2024-012743

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 _________________________________
1275 FAIRFAX RD
SALT LAKE CITY, UT 84103
40001985
PETRO WEST
1
DSL
VRTLS350
8000
92
79 79 79
1.5 1.5 1.5
JOSE CASILLAS
2 3
DSL DSL
VRTLS350
92
8000
VRTLS350
8000
92
11/19/24
SHRINERS HOSPITAL
PE
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8
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 _______________________________________________
1275 FAIRFAX RD
SALT LAKE CITY, UT 84103
40001985
PETRO WEST
DSL
JOSE CASILLAS
SHRINERS HOSPITAL
11/19/24
T1 STP T2 INT T2 STP T3 INT T3 STP
DSL DSL DSL DSL DSL
T1 INT

44 North 800 East  St George, UT 84770  [phone]  Fax [phone]

LINE TEST DATA WORKSHEET

Customer: Date:
Address: Tester:
City/State/Zip: Cert #:

Tank 1 Tank 2 Tank 3 Tank 4
Contents
Pump Manufacturer
Isolation Mechanism
Test Pressure
Initial Cylinder Level
Final Cylinder Level
Leak Rate=(ICL-FCL)X2
Time Started
Time Ended
Total Test Time
Conclusion (Pass or Fail)

LINE LEAK DETECTOR TEST DATA

Tank 1 Tank 2 Tank 3 Tank 4
Serial Number
Resiliency
Opening Time
Test Leak Rate ML/MIN
Holding PSI
Metering PSI
Conclusion (Pass/Fail)

Remarks:___________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
SHRINERS HOSPITAL 11/19/24
1275 E FAIRFAX Jose Casillas
SALT LAK CITY, UT 84103 4E46F605
DSL DSL DSL
RED JACKET RED JACKET RED JACKET
BALL VALVE BALL VALVE BALL VALVE
50 50 50
.0400 ML .0310 ML .0220 ML
.0400 ML .0310 ML .0220 ML
0 0 0
11 AM 12 PM 1:45 PM
12 PM 1 PM 2:45 PM
1 HR 1 HR 1 HR
PASS PASS PASS
Line Test with Petro-Tite.
See leak detector data on form C-9
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 __________________________________
1275 FAIRFAX RD
SALT LAKE CITY, UT 84103
40001985
PETRO WEST
1
DSL
RED JACKET
FX1V
18
.0460
2 SEC
10
2 SEC
JOSE CASILLAS
SHRINERS HOSPITAL
11/19/24
2
DSL
RED JACKET
3
DSL
RED JACK
FXV FXV
28 29 29
18 19
.0310 .0540
2 SEC 2 SEC
10 11
2 SEC 2 SEC
pei.org 53
Recommended Practices for the Testing and Verification of Spill, Overfill, Leak Detection and Secondary Containment Equipment at UST Facilities
APPENDIX C-4
CONTAINMENT SUMP INTEGRITY TESTING
HYDROSTATIC TESTING METHOD
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 test the leak integrity of containment sumps. See PEI/RP1200 Section 6.5 for the test method.
Containment Sump ID
Containment Sump
Material
Liquid and debris
removed from sump?* Yes No Yes No Yes No Yes No Yes No Yes No
Visual Inspection (No
cracks, loose parts
or separation of the
containment sump.)
Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
Containment Sump
Depth
Height From Bottom to
Top of Highest
Penetration
Starting Water Level
Test Start Time
Ending Water Level
Test End Time
Test Period (Minimum
test time: 1 hour)
Water Level Change
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 Pass Fail Pass Fail
Comments:
*All liquids and debris must be disposed of properly.
Tester’s Name (print) ___________________________________ Tester’s Signature _________________________________
1275 FAIRFAX RD
SALT LAKE CITY, UT 84103
40001985
PETRO WEST
T 1STP
FBRGLS
63 IN 55 IN 57 IN
21 IN 20 IN 21 IN
25 IN 24 IN 25 IN
11 AM 1:45 PM 4:00 PM
25 IN 24 IN 25 IN
12 PM 2:45 PM 5:00 PM
1 HR 1 HR 1 HR
0 0 0
JOSE CASILLAS
T2 STP
FBGLS
T3 STP
FBGLS
SHRINERS HOSPITAL
11/19/24