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Home My WebLink AboutDERR-2025-001678pei.org 55 Recommended Practices for the Testing and Verification of Spill, Overfill, Leak Detection and Secondary Containment Equipment at UST Facilities APPENDIX C-5 Tester’s Name (print) ___________________________________ Tester’s Signature __________________________________ UST OVERFILL EQUIPMENT INSPECTION AUTOMATIC SHUTOFF DEVICE AND BALL FLOAT VALVE Facility Name:Owner: Address:Address: City, State, Zip Code:City, State, Zip Code: Facility I.D. #:Phone #: Testing Company:Phone #:Date: This data sheet is for inspecting automatic shutoff devices and ball float valves. See PEI/RP1200 Section 7 for inspection procedures. Product Grade Tank Number Tank Volume, gallons Tank Diameter, inches Overfill Prevention Device Brand 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 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 Yes No Yes No 2. Drop tube and float mecha- nisms free of debris? Yes No Yes No 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 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 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 Yes No Yes No A “No” to any item in Lines 1-5 indicates a test failure. BALL FLOAT VALVE INSPECTION** 1. Tank top fittings vapor- tight and leak-free? Yes No Yes No Yes No Yes No Yes No Yes No 2. Ball float cage free of debris? Yes No 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 Yes No Yes No 4. Vent hole in pipe open and near top of tank? Yes No Yes No Yes No Yes No Yes No Yes No 5. Ball float pipe proper length to restrict flow at 90% capacity?*** Yes No Yes No 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 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 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. 5201 S INTERMOUNTAIN DR MURRAY, UT 84107 279849 PETRO WEST U N L A 1 19,670 117 OPW JOSE CASILLAS COSTCO 764 2/20/25 UNL B 2 19,670 117 OPW PRE 3 19,414 115 OPW PEI/RP1200 -19 pei.org56 APPENDIX C-6 OVERFILL ALARM 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 high level alarm is operational and will trigger when the tank is no more than 90% full. See PEI/RP1200 Section 7.3 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 Tank Level Monitor Brand and Model 1. Tank Volume, gallons 2. Tank Diameter, inches 3. Overfill alarm activates in the test mode at the console? Yes No Yes No Yes No Yes No 4. When activated, overfill alarm can be heard or seen while delivering to the tank? Yes No Yes No Yes No Yes No 5. After removing the probe from the tank, it has been inspected and any damaged or missing parts replaced? Yes No Yes No Yes No Yes No 6. Float moves freely on the stem without binding? Yes No Yes No Yes No Yes No 7. Moving product level float up the stem trigger alarm? Yes No Yes No Yes No Yes No 8. Inch level from bottom of stem when 90% alarm is triggered. 9. Tank volume at inch level in Line 8. 10. Calculate (Line 9 / Line 1) x 100 11. Is Line 10 less than 90%? Yes No Yes No Yes No Yes No 12. Fuel float level on the console agrees with the gauge stick reading? Yes No Yes No Yes No Yes No 13. Overfill alarm activates at any product level above 90% tank capacity? Yes No Yes No Yes No Yes No If any answers in Lines 3, 4, 5, 6, 7 or 11 are “No,” or Line 13 is “Yes,” the system has failed the test. Test Results Pass Fail Pass Fail Pass Fail Pass Fail Comments: Tester’s Name (print) ___________________________________ Tester’s Signature _________________________________ PETRO WEST 2/20/25 1 2 3 4 UNL A UNL B PRE ADD VRTLS350 VRTLS350 VRTLS350 VRTLS350 19,670 19,670 19,414 1514 117 117 115 47 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 90 90 90 90 17,703 17,703 17,473 1363 90 90 90 90 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 JOSE CASILLAS COSTCO 764 5201 S INTERMOUNTAIN DR MURRAY, UT. 84107 279849 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 __________________________________ 5201 S INTERMOUNTAIN DR MURRAY, UT 84107 279849 PETRO WEST 1 UNL VR PLLD 1 JOSE CASILLAS COSTCO 764 2/20/25 2 UNL VR 3 PRE VR PLLD PLLD 4 ADD FEPTRO STPMLD 21 11 .0420 ML 2 SEC 10 2 SEC 28 25 27 1 1 pei.org 61 Recommended Practices for the Testing and Verification of Spill, Overfill, Leak Detection and Secondary Containment Equipment at UST Facilities APPENDIX C-11 EMERGENCY STOP SWITCH 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 verify the operation of all emergency stop switches/buttons (E-stops). Each E-stop must disconnect power to dis- pensers, submersible turbine pumps (STPs) and all non-intrinsically safe electrical equipment in classified areas. Test each E-stop sepa- rately. See PEI/RP1200 Section 11 for the inspection procedure. E-stop Number or ID Location 1. E-stops labeled and located where easily accessible? Yes No Yes No Yes No Yes No Yes No Yes No 2. System fully powered and in normal operating condition? Yes No Yes No Yes No Yes No Yes No Yes No 3. After activating E-stop, power disconnected from: 3a. All dispensing devices on all islands? Yes No Yes No Yes No Yes No Yes No Yes No 3b. All STPs for all fuel grades? Yes No Yes No Yes No Yes No Yes No Yes No 3c. All power, control and signal circuits associat- ed with the dispensing devices and the STPs? Yes No Yes No Yes No Yes No Yes No Yes No 3d. All other non-intrin- sically safe electrical equipment in classified areas surrounding fuel dispensing devices? Yes No Yes No Yes No Yes No Yes No Yes No 4. All intrinsically safe electri- cal equipment remains energized after E-stop acti- vation? Yes No Yes No Yes No Yes No Yes No Yes No 5. After testing, E-stop has been reset and power rees- tablished to normal operat- ing condition? Yes No Yes No Yes No Yes No Yes No Yes No A “No” to lines 3a-3d indicates a test failure. Test Results Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Comments: Tester’s Name (print) ___________________________________ Tester’s Signature __________________________________ COSTCO 764 5201 S INTERMOUNTAIN DR MURRAY, UT 84107 279849 PETRO WEST 2/20/25 1 2 3 KIOSK EAST WEST 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 JOSE CASILLAS 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 _________________________________ 5201 S INTERMOUNTAIN DR MURRAY, UT84107 279849 PETRO WEST 1 UNL A VRTLS350 19,670 117 17,703 17,703 17,473 1363 .8 .8 .8 NA JOSE CASILLAS 2 3 4 UNL B PRE ADD VRTLS350 117 19,670 VRTLS350 19,414 115 VRTLS350 1514 47 2/20/25 COSTCO 764 44 North 800 East  St George, UT 84770  (435) 634-9557  Fax (435) 656-2124 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:___________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ COSTCO 764 2/20/25 5201 S INTERMOUNTAIN DR Jose Casillas MURRAY, UT 84107 4E46F605 UNL UNL PRE ADD GILBARCO GILBARCO GILBARCO GILBARCO BALL VALVE BALL VALVE BALL VALVE BALL VALVE 50 50 50 50 .0210 ML .0350 ML .0160 ML .0410 ML .0210 ML .0350 ML .0160 ML .0410 ML 0 0 0 0 10:30 PM 11:40 PM 1:00 AM 2:00 AM 11:30 PM 12:40 AM 2:00 AM 3:00 AM 1 HR 1 HR 1 HR 1 HR PASS PASS PASS PASS Line Test with Petro-Tite. SEE FORM C9 FOR LEAK DETECTOR INFORMATION PE I / R P 1 2 0 0 -1 9 pe i . o r g 58 AP P E N D I X C - 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 _______________________________________________ 5201 S INTERMOUNTAIN DR MURRAY, UT 84107 279849 PETRO WEST PRE JOSE CASILLAS COSTCO 764 2/20/25 PRE STP DIS 1/2 DIS 3/4 DIS 5/6 DIS 7/8 DIS 9/10 PRE UNL PRE UNL PRE UNL PRE UNL PRE UNL PRE PRE FILL PE I / R P 1 2 0 0 -1 9 pe i . o r g 58 AP P E N D I X C - 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 _______________________________________________ 5201 S INTERMOUNTAIN DR MURRAY, UT 84107 279849 PETRO WEST UNL PRE JOSE CASILLAS COSTCO 764 2/20/25 DIS 13/14 DIS 15/16 ADD STP ADD INT UNL PRE UNL PRE ADD ADD DIS 11/12 PE I / R P 1 2 0 0 -1 9 pe i . o r g 58 AP P E N D I X C - 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 _______________________________________________ 5201 S INTERMOUNTAIN MURRAY, UT 84107 279849 PETRO WEST UNL JOSE CASILLAS COSTCO 764 2/20/25 UNLA FILL UNL A STP UNL B INT UNL B FILL UNL B STP PRE INT UNL UNL UNL UNL UNL PRE UNL A INT Vapor Recovery Test Procedure TP-201.1B Static Torque of Rotatable Phase I Adaptors Adopted: July 3, 2002 Amended: October 8, 2003 California Air Resources Board October 8, 2003 TP-201.1B, Page 1 California Environmental Protection Agency Air Resources Board Vapor Recovery Test Procedure TP-201.1B Static Torque of Rotatable Phase I Adaptors Definitions common to all certification and test procedures are in: D-200 Definitions for Vapor Recovery Procedures For the purpose of this procedure, the term "CARB" refers to the California Air Resources Board, and the term "Executive Officer" refers to the CARB Executive Officer, or his or her authorized representative or designate. 1. PURPOSE AND APPLICABILITY The purpose of this procedure is to quantify the amount of static torque required to start the movement of a rotatable Phase I adaptor and to ensure 360-degree rotation. This procedure determines compliance with the performance specifications set forth in Section 3 of CP-201 Vapor Recovery Certification Procedure. 2. PRINCIPLE AND SUMMARY OF TEST PROCEDURE A compatible dust cap is installed on a rotatable Phase I adaptor. A Torque Test Tool is installed on the dust cap. A socket wrench is installed on the Torque Test Tool and 360- degree rotation is verified. Following the rotation test, a torque wrench is installed on the Torque Test Tool and three static torque measurements are taken. If the resulting, average static torque is less than, or equal to, the maximum allowable value specified in Certification Procedure 201 (CP-201), the adaptor is verified to be in compliance. 3. BIASES AND INTERFERENCES 3.1 Missing or defective gaskets in the dust cap may bias the results towards compliance as a dust cap may slip on the rotatable adaptor prior to the adaptor rotating. This bias is eliminated by ensuring that the dust cap seal is securely in place and does not show signs of excessive wear or damage. 3.2 Gasoline or other lubricants on the sealing surface of the rotatable adaptor or the dust cap seal can cause the dust cap to slip and may bias the results towards compliance. This bias is eliminated by ensuring that the sealing surface of the rotatable adaptor and dust cap is clean, dry and free of lubricants. California Air Resources Board October 8, 2003 TP-201.1B, Page 2 4. SENSITIVITY, RANGE, AND PRECISION 4.1 Torque Wrench. The maximum full-scale range shall be 250 pound-inches with minimum accuracy of 3.0 percent full-scale and minimum readability of 5 pound-inch increments. The torque wrench shall incorporate a mechanism, such as a tell-tale needle that identifies the maximum applied torque during each measurement. 5. EQUIPMENT 5.1 Torque Wrench. Use a Snap-On® Model TER12FUA Torque Wrench, or equivalent, to measure the static torque of the rotatable adaptor. 5.2 Static Torque Test Assembly. Use a compatible dust cap and rotatable adaptor Torque Test Tool, Phil-Tite® Part Number 6004, or equivalent. A depiction of a Torque Test Tool is shown in Figure 1. An example of a Static Torque Test Assembly is shown in Figure 2. 5.3 Socket wrench and socket extension. Use a 3/8 inch or ½ inch socket wrench, adaptors and socket extension (if needed) to verify 360-degree rotation or to conduct static torque testing. The socket extension shall not exceed 12 inches in length. Figure 1 Phil-Tite® Torque Test Tool California Air Resources Board October 8, 2003 TP-201.1B, Page 3 Figure 2 Static Torque Test Assembly 6. PRE-TEST PROCEDURES 6.1 Remove the lids of the Phase I spill containers. Visually determine that the adaptors are of the rotatable design. 6.2 Inspect the dust caps to ensure that the caps and that the gaskets are intact and do not show signs of excessive wear or damage. 6.3 Inspect the rotatable adaptors. If the adaptors are wet or covered with a lubricant, wipe the adaptors clean to ensure maximum friction between the dust cap and the adaptor seal surface. 7. TEST PROCEDURE 7.1 Install the dust cap on the Phase I rotatable adaptor. 7.2 Install the Torque Test Tool on the dust cap as shown in Figure 2. Torque Test Tool Dust Cap Rotatable Adapter Torque Test Assembly California Air Resources Board October 8, 2003 TP-201.1B, Page 4 7.3 Verification of rotation, conducted prior to the Static Torque Test. Place a socket wrench with socket extension (if required ) into the Torque Test Tool, or equivalent. Rotate the adaptor a minimum of 360 degrees. Do not continue with static torque measurements if the adaptor does not rotate 360 degrees. Record the result on the data sheet where provided. 7.4 Install the Torque Wrench into the Torque Test Tool. If the spill container is too deep to allow connection of the Torque Wrench, use a compatible socket extension to reach into the bucket to the Torque Test Tool. The socket extension shall not exceed 12 inches in length. 7.5 Place one hand on top of the Torque Wrench, directly above the center of the Torque Test Tool to keep the wrench level while applying pressure. Gently apply an even, steady pressure just until the adaptor begins to rotate. Record the maximum applied static torque value shown on the torque wrench and proceed to 7.6. 7.6 After the first measurement, slowly rotate the adaptor one third of full rotation (120 degrees) from the point that the first measurement was taken. Using the same technique described in 7.5, measure and record the second torque measurement. 7.7 Following the first two measurements, slowly rotate the adaptor another, one third of full rotation (120 degrees) from the second measurement location. Using the same technique as described in 7.5, measure and record the third torque measurement. Rotating the adaptor in one-third increments ensures that the average static torque is representative of the entire adaptor rotation. 8. POST-TEST PROCEDURES 8.1 Remove the Torque Test Assembly and replace the appropriate lids on each of the spill containers. Store all test equipment in a protected location to prevent damage to the equipment. 9. CALCULATING RESULTS 9.1 Calculate the arithmetic average of the three tests for each adaptor tested and record the value on the data sheet where provided. 10. REPORTING RESULTS 10.1 Report the results of the static torque measurements on the data sheet where provided. Alternate data sheets may be used provided they include the same parameters identified on Form 1. 11. ALTERNATE PROCEDURES 11.1 This procedure shall be conducted as specified. Modifications to this test procedure shall not be used to determine compliance unless prior written approval has been obtained from the Executive Officer, pursuant to Section 14 of Certification Procedure CP-201. California Air Resources Board October 8, 2003 TP-201.1B, Page 5 Form 1 Static Torque of Rotatable Phase I Adaptors Measurement Units: (circle one): pound-inches pound-feet Vapor Adaptor 1 Vapor Adaptor 2 Vapor Adaptor 3 Vapor Adaptor 4 Brand:Brand:Brand:Brand: Model:Model:Model:Model: Grade:Grade:Grade:Grade: Torque 1:Torque 1:Torque 1:Torque 1: Torque 2:Torque 2:Torque 2:Torque 2: Torque 3:Torque 3:Torque 3:Torque 3: Average:Average:Average:Average: 360 Rotation: Yes / No 360 Rotation: Yes / No 360 Rotation: Yes / No 360 Rotation: Yes / No Product Adaptor 1 Product Adaptor 2 Product Adaptor 3 Product Adaptor 4 Brand:Brand:Brand:Brand: Model:Model:Model:Model: Grade:Grade:Grade:Grade: Torque 1:Torque 1:Torque 1:Torque 1: Torque 2:Torque 2:Torque 2:Torque 2: Torque 3:Torque 3:Torque 3:Torque 3: Average:Average:Average:Average: 360 Rotation: Yes / No 360 Rotation: Yes / No 360 Rotation: Yes / No 360 Rotation: Yes / No Comments: ___________________________________________________________________ Test Company:Conducted By: Test Date:Facility Name: Facility Address:City: PETRO WEST JOSE CASILLAS 2/20/25 COSTCO #764 5201 S INTERMOUNTAIN MURRAY, UT 84107 OPW OPW OPW 61VS 61VS 61VS Unleaded 87 Unleaded 87 Premium 91 10 10 14 11 10 14 11 10 1 11 10 14 OPW OPW OPW 61SA 61SA 61SA Unleaded 87 Unleaded 87 Premium 91 OFF SCALE OFF SCALE OFF SCALE ALL FILL ADAPTERS FAILED. WILL REPLACE AND TEST. Vapor Recovery Test Procedure TP-201.1B Static Torque of Rotatable Phase I Adaptors Adopted: July 3, 2002 Amended: October 8, 2003 California Air Resources Board October 8, 2003 TP-201.1B, Page 1 California Environmental Protection Agency Air Resources Board Vapor Recovery Test Procedure TP-201.1B Static Torque of Rotatable Phase I Adaptors Definitions common to all certification and test procedures are in: D-200 Definitions for Vapor Recovery Procedures For the purpose of this procedure, the term "CARB" refers to the California Air Resources Board, and the term "Executive Officer" refers to the CARB Executive Officer, or his or her authorized representative or designate. 1. PURPOSE AND APPLICABILITY The purpose of this procedure is to quantify the amount of static torque required to start the movement of a rotatable Phase I adaptor and to ensure 360-degree rotation. This procedure determines compliance with the performance specifications set forth in Section 3 of CP-201 Vapor Recovery Certification Procedure. 2. PRINCIPLE AND SUMMARY OF TEST PROCEDURE A compatible dust cap is installed on a rotatable Phase I adaptor. A Torque Test Tool is installed on the dust cap. A socket wrench is installed on the Torque Test Tool and 360- degree rotation is verified. Following the rotation test, a torque wrench is installed on the Torque Test Tool and three static torque measurements are taken. If the resulting, average static torque is less than, or equal to, the maximum allowable value specified in Certification Procedure 201 (CP-201), the adaptor is verified to be in compliance. 3. BIASES AND INTERFERENCES 3.1 Missing or defective gaskets in the dust cap may bias the results towards compliance as a dust cap may slip on the rotatable adaptor prior to the adaptor rotating. This bias is eliminated by ensuring that the dust cap seal is securely in place and does not show signs of excessive wear or damage. 3.2 Gasoline or other lubricants on the sealing surface of the rotatable adaptor or the dust cap seal can cause the dust cap to slip and may bias the results towards compliance. This bias is eliminated by ensuring that the sealing surface of the rotatable adaptor and dust cap is clean, dry and free of lubricants. California Air Resources Board October 8, 2003 TP-201.1B, Page 2 4. SENSITIVITY, RANGE, AND PRECISION 4.1 Torque Wrench. The maximum full-scale range shall be 250 pound-inches with minimum accuracy of 3.0 percent full-scale and minimum readability of 5 pound-inch increments. The torque wrench shall incorporate a mechanism, such as a tell-tale needle that identifies the maximum applied torque during each measurement. 5. EQUIPMENT 5.1 Torque Wrench. Use a Snap-On® Model TER12FUA Torque Wrench, or equivalent, to measure the static torque of the rotatable adaptor. 5.2 Static Torque Test Assembly. Use a compatible dust cap and rotatable adaptor Torque Test Tool, Phil-Tite® Part Number 6004, or equivalent. A depiction of a Torque Test Tool is shown in Figure 1. An example of a Static Torque Test Assembly is shown in Figure 2. 5.3 Socket wrench and socket extension. Use a 3/8 inch or ½ inch socket wrench, adaptors and socket extension (if needed) to verify 360-degree rotation or to conduct static torque testing. The socket extension shall not exceed 12 inches in length. Figure 1 Phil-Tite® Torque Test Tool California Air Resources Board October 8, 2003 TP-201.1B, Page 3 Figure 2 Static Torque Test Assembly 6. PRE-TEST PROCEDURES 6.1 Remove the lids of the Phase I spill containers. Visually determine that the adaptors are of the rotatable design. 6.2 Inspect the dust caps to ensure that the caps and that the gaskets are intact and do not show signs of excessive wear or damage. 6.3 Inspect the rotatable adaptors. If the adaptors are wet or covered with a lubricant, wipe the adaptors clean to ensure maximum friction between the dust cap and the adaptor seal surface. 7. TEST PROCEDURE 7.1 Install the dust cap on the Phase I rotatable adaptor. 7.2 Install the Torque Test Tool on the dust cap as shown in Figure 2. Torque Test Tool Dust Cap Rotatable Adapter Torque Test Assembly California Air Resources Board October 8, 2003 TP-201.1B, Page 4 7.3 Verification of rotation, conducted prior to the Static Torque Test. Place a socket wrench with socket extension (if required ) into the Torque Test Tool, or equivalent. Rotate the adaptor a minimum of 360 degrees. Do not continue with static torque measurements if the adaptor does not rotate 360 degrees. Record the result on the data sheet where provided. 7.4 Install the Torque Wrench into the Torque Test Tool. If the spill container is too deep to allow connection of the Torque Wrench, use a compatible socket extension to reach into the bucket to the Torque Test Tool. The socket extension shall not exceed 12 inches in length. 7.5 Place one hand on top of the Torque Wrench, directly above the center of the Torque Test Tool to keep the wrench level while applying pressure. Gently apply an even, steady pressure just until the adaptor begins to rotate. Record the maximum applied static torque value shown on the torque wrench and proceed to 7.6. 7.6 After the first measurement, slowly rotate the adaptor one third of full rotation (120 degrees) from the point that the first measurement was taken. Using the same technique described in 7.5, measure and record the second torque measurement. 7.7 Following the first two measurements, slowly rotate the adaptor another, one third of full rotation (120 degrees) from the second measurement location. Using the same technique as described in 7.5, measure and record the third torque measurement. Rotating the adaptor in one-third increments ensures that the average static torque is representative of the entire adaptor rotation. 8. POST-TEST PROCEDURES 8.1 Remove the Torque Test Assembly and replace the appropriate lids on each of the spill containers. Store all test equipment in a protected location to prevent damage to the equipment. 9. CALCULATING RESULTS 9.1 Calculate the arithmetic average of the three tests for each adaptor tested and record the value on the data sheet where provided. 10. REPORTING RESULTS 10.1 Report the results of the static torque measurements on the data sheet where provided. Alternate data sheets may be used provided they include the same parameters identified on Form 1. 11. ALTERNATE PROCEDURES 11.1 This procedure shall be conducted as specified. Modifications to this test procedure shall not be used to determine compliance unless prior written approval has been obtained from the Executive Officer, pursuant to Section 14 of Certification Procedure CP-201. California Air Resources Board October 8, 2003 TP-201.1B, Page 5 Form 1 Static Torque of Rotatable Phase I Adaptors Measurement Units: (circle one): pound-inches pound-feet Vapor Adaptor 1 Vapor Adaptor 2 Vapor Adaptor 3 Vapor Adaptor 4 Brand:Brand:Brand:Brand: Model:Model:Model:Model: Grade:Grade:Grade:Grade: Torque 1:Torque 1:Torque 1:Torque 1: Torque 2:Torque 2:Torque 2:Torque 2: Torque 3:Torque 3:Torque 3:Torque 3: Average:Average:Average:Average: 360 Rotation: Yes / No 360 Rotation: Yes / No 360 Rotation: Yes / No 360 Rotation: Yes / No Product Adaptor 1 Product Adaptor 2 Product Adaptor 3 Product Adaptor 4 Brand:Brand:Brand:Brand: Model:Model:Model:Model: Grade:Grade:Grade:Grade: Torque 1:Torque 1:Torque 1:Torque 1: Torque 2:Torque 2:Torque 2:Torque 2: Torque 3:Torque 3:Torque 3:Torque 3: Average:Average:Average:Average: 360 Rotation: Yes / No 360 Rotation: Yes / No 360 Rotation: Yes / No 360 Rotation: Yes / No Comments: ___________________________________________________________________ Test Company:Conducted By: Test Date:Facility Name: Facility Address:City: PETRO WEST JOSE CASILLAS 2/20/25 COSTCO #764 5201 S INTERMOUNTAIN MURRAY, UT 84107 OPW OPW OPW 61VS 61VS 61VS Unleaded 87 Unleaded 87 Premium 91 10 10 14 11 10 14 11 10 14 11 10 14 OPW OPW OPW 61SA 61SA 61SA Unleaded 87 Unleaded 87 Premium 91 22 20 21 22 19 20 22 19 20 22 19 20 ALL FILL AND VAPOR ADAPTERS PASS Page 1 of 1 Rev. 04/27/2020 LEAK RATE OF PRESSURE/VACUUM RELIEF VENT VALVES TEST RESULT FORM (40 CFR Part 63, Subpart CCCCCC) Initial Triennial Other Source Name: Source ID: Source Address: (address) (city) (zip) Date of Test: Time of Test: Valve 1: Grade (Check One) 87 89 91 Other Manifolded P/V Valve Manufacturer: Model Number: Measured 2.00 inch Leak Rate (CFH): Positive Cracking Pressure (“w.c.): Measured 4.00 inch Leak Rate (CFH): Negative Cracking Pressure (“w.c.): Pass Fail Pass Fail Pass Fail Pass Fail Valve 2: Grade (Check One) 87 89 91 Other Manifolded P/V Valve Manufacturer: Model Number: Measured 2.00 inch Leak Rate (CFH): Positive Cracking Pressure (“w.c.): Measured 4.00 inch Leak Rate (CFH): Negative Cracking Pressure (“w.c.): Pass Fail Pass Fail Pass Fail Pass Fail Valve 3: Grade (Check One) 87 89 91 Other Manifolded P/V Valve Manufacturer: Model Number: Measured 2.00 inch Leak Rate (CFH): Positive Cracking Pressure (“w.c.): Measured 4.00 inch Leak Rate (CFH): Negative Cracking Pressure (“w.c.): Pass Fail Pass Fail Pass Fail Pass Fail Common conversion factors: 0.17 CFH = 80ml/min, 0.21 CFH = 100ml/min, 0.42 CFH= 200ml/min, 0.25=120ml/min Comments: 4701 W. Russell Road 2nd FloorLas Vegas, NV 89118-2231Phone: (702) 455-5942 Fax: (702) 383-9994 Marci Henson, Director 4 COSTCO 764 5201 S INTERMOUNTAIN DR MURRAY 84107 2/20/25 11:30 PM 4 OPW 623V 0 4 3.13 4 0 4 6.6 4 EXISTING VALVE PASSED COM-SS-GDO-003 Page 1 of 1 Rev. 04/27/2020 PRESSURE DECAY TEST RESULTS FORM Other Source Name: Source ID: Source Address: (address) (city) (zip) Test Date: Time of Test: Date and Time of Most Recent Fuel Delivery: Pressure Measuring Device: Device Calibration Date: Note: Phase II EVR Executive Orders (EO) contain requirements (see below) which must be met when conducting a pressure decay test. These requirements must be followed in accordance with the applicable E.O. in order for the pressure decay test result to be valid. Tank Number: 1 2 3 4 Total Product Grade: Tank Capacity, gallons: Distance of highest point of discharge of fill-pipe from tank bottom. (inches) Gasoline, gallons: Ullage, gallons1: Initial Pressure1, wcg: Pressure @ 1 minute: Pressure @ 2 minutes: Pressure @ 3 minutes: Pressure @ 4 minutes: Final pressure @ 5 minutes: Allowable Final Pressure, wcg: Pressure Decay Test Results: P/ F P/ F P/ F P/ F P/ F 1The minimum total ullage for each individual tank shall be 1,000 gallons or 25% of the tank capacity, whichever is less. The maximum total ullage for all manifolded tanks shall not exceed 25,000 gallons. Comments: ,QLWLDO 7ULHQQLDO 40:5XVVHOO5RDG2QG)ORRU/DV9HJDV19223KRQH02442)D[0240DUFL+HQVRQ'LUHFWRU ! COSTCO 764 5201 S INTERMOUNTAIN DR MURRAY 84107 2/20/25 11:00 PM FEB 20, 2025 7:16 PM Dwyer mark III 475 7/24 UNL UNL PRE 20,000 20,000 20,000 60,000 4 4 4 14,314 14,427 14,127 42,868 5,356 5,243 5,287 15,886 2.0 2.0 1.98 1.96 1.95 1.95 1.90 ✔ TEST PASSES WITH NO REPAIRS. Page 1 of 2 Revised 11/18/2019 Location Name: Date: Address: City: State: Procedure: Visually inspect each containment sump for the presence of liquid or debris is present, provide details and action taken to clean the sump. Visually inspect the sump and sump fittings for cracks, holes, bulges, or other defects. If “N” is entered for any items, the sump Fails. Provide details for all follow-up action required in the appropriate comments section. Sump is clean and dry with no visual fuel leaks Sump lid and gaskets present and in good condition Penetration fittings are free of visual defects Sump walls and bottom are free of visual defects Sump sensor is properly positioned and secure Secondary piping test boots positioned to allow drainage Pass or Fail Tank Sumps 87 A Turbine Sump Yes No Yes No Yes No Yes No Yes No Yes No Pass Fail 87 A Fill Sump Yes No Yes No Yes No Yes No Yes No Yes No Pass Fail 87 B Turbine Sump Yes No Yes No Yes No Yes No Yes No Yes No Pass Fail 87 B Fill Sump Yes No Yes No Yes No Yes No Yes No Yes No Pass Fail 91 Turbine Sump Yes No Yes No Yes No Yes No Yes No Yes No Pass Fail 91 Fill Sump Yes No Yes No Yes No Yes No Yes No Yes No Pass Fail Diesel Turbine Sump: Yes No Yes No Yes No Yes No Yes No Yes No Pass Fail Diesel Fill Sump Yes No Yes No Yes No Yes No Yes No Yes No Pass Fail Gas Additive Sump Yes No Yes No Yes No Yes No Yes No Yes No Pass Fail Diesel Additive Sump Yes No Yes No Yes No Yes No Yes No Yes No Pass Fail Other Tank Sump: Yes No Yes No Yes No Yes No Yes No Yes No Pass Fail Other Tank Sump: Yes No Yes No Yes No Yes No Yes No Yes No Pass Fail Tank Sump Comments and Follow-up Action Required Annual Walkthrough/Containment Sump Inspection Form IMPORTANT: This form is only to be used if the State or local UST agency does not have a required form for the Annual Walkthrough Inspection. COSTCO 764 2/20/25 5201 S INTERMOUNTAIN MURRAY UT 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 Page 2 of 2 Revised 11/18/2019 Sump is clean and dry with no visual fuel leaks Sump lid and gaskets present and in good condition Penetration fittings are free of visual Sump walls and bottom are free of visual defects Sump sensor is properly positioned and secure Secondary piping test boots positioned to allow drainage Pass or Fail Under Dispenser Containment Sumps Dispenser 1/2 Yes No Yes No Yes No Yes No Yes No Yes No Pass Fail Dispenser 3/4 Yes No Yes No Yes No Yes No Yes No Yes No Pass Fail Dispenser 5/6 Yes No Yes No Yes No Yes No Yes No Yes No Pass Fail Dispenser 7/8 Yes No Yes No Yes No Yes No Yes No Yes No Pass Fail Dispenser 9/10 Yes No Yes No Yes No Yes No Yes No Yes No Pass Fail Dispenser 11/12 Yes No Yes No Yes No Yes No Yes No Yes No Pass Fail Dispenser 13/14 Yes No Yes No Yes No Yes No Yes No Yes No Pass Fail Dispenser 15/16 Yes No Yes No Yes No Yes No Yes No Yes No Pass Fail Dispenser 17/18 Yes No Yes No Yes No Yes No Yes No Yes No Pass Fail Dispenser 19/20 Yes No Yes No Yes No Yes No Yes No Yes No Pass Fail Dispenser 21/22 Yes No Yes No Yes No Yes No Yes No Yes No Pass Fail Dispenser 23/24 Yes No Yes No Yes No Yes No Yes No Yes No Pass Fail Vent Box and Other Miscellaneous Containment Sumps Vent Box Yes No Yes No Yes No Yes No Yes No Yes No Pass Fail Other Sump: Yes No Yes No Yes No Yes No Yes No Yes No Pass Fail Other Sump: Yes No Yes No Yes No Yes No Yes No Yes No Pass Fail Other Sump: Yes No Yes No Yes No Yes No Yes No Yes No Pass Fail UDC and Miscellaneous Containment Sump Comments and Follow-up Action Required Tester’s Signature: Date: JOSE CASILLAS 2/20/25 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 UST Sump Extinguisher Verification Location Name: Date: Address: City: State: Extinguisher is in place and Secure? Extinguisher arrow is in the Green? Comments/Follow-up Action Required Tank Sumps 87 A Turbine Sump Yes No Yes No 87 A Fill Sump Yes No Yes No 87 B Turbine Sump Yes No Yes No 87 B Fill Sump Yes No Yes No 91 Turbine Sump Yes No Yes No 91 Fill Sump Yes No Yes No Gas Additive Tank Sump Yes No Yes No Diesel Turbine Sump: Yes No Yes No Diesel Fill Sump Yes No Yes No Diesel Additive Tank Sump Yes No Yes No Under Dispenser Containment Sumps Dispenser 1/2 Yes No Yes No Dispenser 3/4 Yes No Yes No Dispenser 5/6 Yes No Yes No Dispenser 7/8 Yes No Yes No Dispenser 9/10 Yes No Yes No Dispenser 11/12 Yes No Yes No Dispenser 13/14 Yes No Yes No Dispenser 15/16 Yes No Yes No Dispenser 17/18 Yes No Yes No Dispenser 19/20 Yes No Yes No Dispenser 21/22 Yes No Yes No Dispenser 23/24 Yes No Yes No Other Miscellaneous Containment Sumps Vent Box Yes No Yes No Other Sump: Yes No Yes No Other Sump: Yes No Yes No Other Sump: Yes No Yes No Other Sump: Yes No Yes No Revised 09/23/2019 Tester’s Signature: Date: COSTCO #764 2/20/25 5201 S INTERMOUNTAIN MURRAY UT No diesel tanks at this site. JOSE CASILLAS 2/20/25 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 Revised 12/11/2019 Stage I Vapor Recovery System Survey Location Name: Date: Address: Testing Company: City, State, Zip Technician Name: Tank Top Equipment Tank 1 Tank 2 Tank 3 Tank 4 Tank 5 Tank ID Product Stored Fill Type Single Dual Single Dual Single Dual Single Dual Single Dual Does the drop tube have a flapper/overfill prevention valve? Yes No Yes No Yes No Yes No Yes No Are drop tubes cages installed? Yes No Yes No Yes No Yes No Yes No Drop Tube Clearance (inches) Fill Adapter Type Swivel Fixed Swivel Fixed Swivel Fixed Swivel Fixed Swivel Fixed Vapor Adapter Type Swivel Fixed Swivel Fixed Swivel Fixed Swivel Fixed Swivel Fixed Vent Caps Vent 1 Vent 2 Vent 3 Vent 4 Vent 5 Manufacturer Model Number Labeled Positive Cracking Pressure Labeled Negative Cracking Pressure Comments/Deficiencies: Tester's Signature: Date: COSTCO #764 2/20/25 5201 S INTERMOUNTAIN PETRO WEST : MURRAY, UT 84107 JOSE CASILLAS Unleaded 87A Unleaded 87B Premium Additive Unleaded Unleaded Premium Additive 6"6"6"N/A JOSE CASILLAS 2/20/25 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 Facility: Date: Address: Testing Company: City, State, Zip: Tester Name: This data sheet is for inspecting shear valves located inside dispensers. See PEI/RP1200 Section 10 for the inspection procedure. Product Grade: Dispenser ID# Shear Valve Type (Product/Vapor) 1. Is the shear valve rigidly anchored to the dispenser box frame or dispenser island? Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No 2. Is the shear section positioned between 1/2 inch above or below the top surface of the dispenser island? Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No 3. Is the lever arm free to move? Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA 4. Does the lever arm snap shut the poppet valve? Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA 5. Can any product be dispensed when the shear valve is closed? Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA A "No" to lines 1-4 or a "Yes" for Line 5 indicates a test failure. Test Results:  Pass  Fail  Pass  Fail  Pass  Fail  Pass  Fail  Pass  Fail  Pass  Fail  Pass  Fail  Pass  Fail  Pass  Fail  Pass  Fail Comments: Tester's Signature: Date: Rev. 12/15/2017 Shear Valve Operation Inspection 2/20/25 PETRO WEST JOSE CASILLAS JOSE CASILLAS 2/20/25 UNL 1&2 PRODUCT PRE 1&2 PRODUCT UNL 3&4 PRODUCT PRE 3&4 PROIDUCT UNL 5&6 PRODUCT PRE 5&6 PRODUCT UNL 7&8 PRODUCT PRE 7&8 PRODUCT UNL 9&10 PRODUCT PRE 9&10 PRODUCT COSTCO #764 5201 S INTERMOUNTAIN MURRAY, UT 84107 Facility: Date: Address: Testing Company: City, State, Zip: Tester Name: This data sheet is for inspecting shear valves located inside dispensers. See PEI/RP1200 Section 10 for the inspection procedure. Product Grade: Dispenser ID# Shear Valve Type (Product/Vapor) 1. Is the shear valve rigidly anchored to the dispenser box frame or dispenser island? Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No 2. Is the shear section positioned between 1/2 inch above or below the top surface of the dispenser island? Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No 3. Is the lever arm free to move? Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA 4. Does the lever arm snap shut the poppet valve? Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA 5. Can any product be dispensed when the shear valve is closed? Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA A "No" to lines 1-4 or a "Yes" for Line 5 indicates a test failure. Test Results:  Pass  Fail  Pass  Fail  Pass  Fail  Pass  Fail  Pass  Fail  Pass  Fail  Pass  Fail  Pass  Fail  Pass  Fail  Pass  Fail Comments: Tester's Signature: Date: Rev. 12/15/2017 Shear Valve Operation Inspection 2/20/25 PETRO WEST JOSE CASILLAS JOSE CASILLAS 2/20/25 UNL 11&12 PRODUCT PRE 11&12 PRODUCT UNL 13&14 PRODUCT PRE 13&14 PRODUCT UNL 15&16 PRODUCT PRE 15&16 PRODCUT COSTCO #764 5201 S INTERMOUNTAIN MURRAY, UT 84107