DERR-2024-013204

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: 12/18/2024
UTAH DEPARTMENT OF ENV. QUALITY
UST
PO Box 144840
SALT LAKE CITY, UT 84114
Test Date: 12/9/2024
Order Number: 2373762
Dear Regulator,
Enclosed are the results of recent testing performed at the following facility:
WALMART #WM5270
629 N STATE ST
LINDON, UT 84042
Testing performed:
Sincerely,
Dawn Kohlmeyer
Manager, Field Reporting
Product Line Tightness Test Page 1 of 1
Work Order: 2373762 Date: 12/9/2024
Site Name/ID: WALMART #WM5270 / WM5270
Address: 629 N STATE ST
City: LINDON State: UT Zip: 84042
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
1
RUL
Pressure
60
08:57
09:57
0.00
Pass
Yes
Tank # 2
Line # 1
TLD-1
2
RUL 2
Pressure
60
08:57
09:57
0.00
Pass
Yes
Tank # 3
Line # 1
TLD-1
3
PREMIUM
Pressure
60
08:57
09:57
0.00
Pass
Yes
Tank # 3
Line # 2
TLD-1
3
PREMIUM
Pressure
60
08:57
09:57
0.00
Pass
Yes
Tank # 4
Line # 1
TLD-1
4
Low Sulfur
Diesel
Pressure
60
08:57
09:57
0.00
Pass
Yes
Tank # 4
Line # 2
TLD-1
4
Low Sulfur
Diesel
Pressure
60
08:57
09:57
0.00
Pass
Yes
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
WALMART #WM5270
629 N STATE ST
LINDON UT 84042
WM5270
Tanknology, Inc.
WALMART/SAM'S CLUB
DEPT. 9641 2101 SE Simple Savings Dr.
BENTONVILLE AR 72716
479-360-2779
12/09/2024
RUL RUL 2 Low Sulfur
DieselVeeder Root
DPLLD
Veeder Root
DPLLD
Veeder Root
DPLLD
Veeder Root
DPLLD
38
2
38
2 2
37 40
2
UT151
David Mathie
NW1-2373762
PREMIUM
T1:1 T2:1 T3:1 T4:1
Impact Valve
Inspection
Impact Valve Operational
Inspection
Work Order:2373762 Date:12/9/2024
Site Name/ID:WALMART #WM5270
Address:629 N STATE ST
City:LINDON State:UT Zip:84042
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 40 Pass Fail Not Tested
7/8 85 Pass Fail Not Tested
7/8 91 Pass Fail Not Tested
9/10 40 Pass Fail Not Tested
9/10 85 Pass Fail Not Tested
9/10 91 Pass Fail Not Tested
11/12 85 Pass Fail Not Tested
11/12 91 Pass Fail Not Tested
13/14 85 Pass Fail Not Tested
13/14 91 Pass Fail Not Tested
15/16 40 Pass Fail Not Tested
15/16 85 Pass Fail Not Tested
15/16 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
WALMART #WM5270 WALMART/SAM'S CLUB
629 N STATE ST
LINDON UT 84042
WM5270
Tanknology, Inc.
DEPT. 9641 2101 SE Simple Savings Dr.
BENTONVILLE AR 72716
479-360-2779
800-964-1250 12/09/2024
1 2 3 4
RUL1 RUL2 PREM DSL
VR450PLUS VR450PLUS VR450PLUS VR450PLUS
19782 11904 7901 10420
119.4 119.4 119.4 119.4
UT151
David Mathie
629 N STATE ST
WALMART #WM5270
629 N STATE ST, LINDON, UT 84042
WM5270
Tanknology, Inc.
WALMART/SAM'S CLUB
DEPT. 9641 2101 SE Simple Savings Dr.
BENTONVILLE, AR 72716
479-360-2779
12/09/2024
ANNULAUR ANNULAR ANNULAR STP STP STP STP
RUL1 RUL2/PREM DSL RUL1 RUL2 PREM DSL
UT151
David Mathie
629 N STATE ST
WALMART #WM5270
629 N STATE ST, LINDON, UT 84042
WM5270
Tanknology, Inc.
WALMART/SAM'S CLUB
DEPT. 9641 2101 SE Simple Savings Dr.
BENTONVILLE, AR 72716
479-360-2779
12/09/2024
UDC UDC UDC UDC UDC UDC UDC
1/2 3/4 5/6 7/8 9/10 11/12 13/14
UT151
David Mathie
629 N STATE ST
WALMART #WM5270
629 N STATE ST, LINDON, UT 84042
WM5270
Tanknology, Inc.
WALMART/SAM'S CLUB
DEPT. 9641 2101 SE Simple Savings Dr.
BENTONVILLE, AR 72716
479-360-2779
12/09/2024
UDC
15/16
David Mathie
WALMART #WM5270
629 N STATE ST
LINDON, UT 84042
WM5270
Tanknology, Inc.
WALMART/SAM'S CLUB
479-360-2779
12/09/2024
DEPT. 9641 2101 SE Simple Savings Dr.
BENTONVILLE, AR 72716
1
RUL
5
OPW
2
RUL
5
OPW
3
PREM
5
OPW
4
DSL
5
OPW
15 WC
849
15 WC
859
5 MIN
0
15 WC
842
15 WC
847
5 MIN
0
15 WC
835
14 WC
849
5 MIN
1 WC
15 WC
828
15 WC
838
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 12/9/2024 Work Order 2373762
Cust Name / Location Number WM5270
Street Address 629 N STATE ST
City, State, ZipCode LINDON UT 84042

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
1
RUL
Dual Point
Straight w/ Flapper
6.00
Swivel
Swivel (poppet)
No

GAS
Pressure Vacuum cap
3
8
2
RUL 2
Dual Point
Straight w/ Flapper
5.00
Swivel
Swivel (poppet)
No

3
PREMIUM
Dual Point
Straight w/ Flapper
6.00
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
12/9/2024
UST Facility Person Conducting Test
Facility Name
WALMART #WM5270
Facility ID #
WM5270
Tester's Name
DMATHIE
Physical Address
629 N STATE ST
Company
Tanknology Inc.
City
LINDON
County
UTAH
State
UT
Certification #
41442
Expiration Date
10/20/2025
UST Owner
WALMART/SAM'S CLUB
Tester's Signature Date
12/9/2024
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:1 RUL - 1
Y
Y
Y
Y
N
Pass
STP:2 RUL 2 - 1
Y
Y
Y
Y
N
Pass
STP:3 PREMIUM - 1
Y
Y
Y
Y
N
Pass
STP:4 Low Sulfur Diesel -
1
Y
Y
Y
Y
N
Pass
Comments:

WO: 2373762
Site Diagram
(This site diagram is for reference only and is not drawn to scale)

Work Order:2373762
Site ID / Name:WM5270 / WALMART #WM5270
Address:629 N STATE ST
City:LINDON State:UT Zip:84042