DERR-2025-002319

UTAH STATE FUEL NETWORK AST ANNUAL INSPECTION
Facility Name and Site Address: Date:
Facility ID #
Purpose:Regular Reinspection Complaints Annual Inspection
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Pumps Tested for Calibration
Is tank grounding strap in good condition ?
Is tank coating free of corrosion / damage ?
Is tank free of noticable distortion, denting, buckeling ?
Flanged connection bolts appear tight ?
Normal and emergency vents appear in good condition ?
Inspection Remarks:
Technician signature
Inspected By: Steven B. Martin UT121
Applied Environmental Services L.C.
MONTEZUMA CREEK ELEMENTARY
2-27-2025
5000164
State Fuel Contact : Brett Gurney 385-602-4872
801-540 9258 [e-mail]
Email: [e-mail]
Fill and vapor connections in good condition ?
AST WITH ABOVEGROUND PRODUCT LINES
INSTALLED NEW PV VALVE ON UNLEADED VENT
Tank containment structure in satisfactory condition ?
Free of tank settlement and foundation washout ?
Tank supports in satisfactory condition ?
Is water able to drain off tank pad and tank top ?
Gasoline vent has P/V valve installed where required ?
Valves / syphons / solenoids appear in good condition ?
Spill containment visable and appears in good condition
Electrical junction boxes and conduits in good condition
Tank monitor free of active alarms ?
Emergency shutoff installed ?
Dispenser static test ?
Tank overfill equipment installed ?
Piping sumps appear in good condition ?
COMMENTS / ACTION
Digitally signed by STEVEN B MARTIN
cn=STEVEN B MARTIN, o=AES, c=US
Date: 2025.03.11 10:32:06 -07'00'
Reason: I am the author of this document
AUTOMATIC TANK GAUGE OPERATION INSPECTION
Facility Name:
Address:
City, State, Zip Code:
Facility I.D. #
Testing Company:
Owner:
Address:
City, State, Zip Code:
Phone #
Testers Phone #
Date:
This procedure is to determine whether the ( ATG) is operating properly. See PEI/RP1200 Section 8.2 for the proper inspection procedure.
Tank Number
Product Stored:
ATG Brand and Model
1. Tank Volume, gallons
2. Tank Diameter, inches
3. After removing the ATG from the tank, has it
been inspected and any damaged or missing
parts replaced?
4. Float moves freely on the stem without
5. Fuel float level agrees with the
value programmed into the console?
6. Water float level agrees with the value
programmed into the console?
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?
9. Inch level from the bottom when the water
float first triggers an alarm.
10. Inch level at which the float alarm activates
corresponds with value programmed in the
gauge?
If any answers in Lines 3,4,5, or 6 are "NO" the system has failed the test.
TEST RESULTS
Comments:
Testers Name: Steven B. Martin Testers Signature:
MONTEZUMA CREEK ELEMENTARY
MONTEZUMA CREEK, UTAH
5000164
AES UTAH TESTER # UT 0121
STATE FUEL NETWORK
PO BOX 141152
SALT LAKE CITY, UTAH 84141-1152
BRETT GURNEY 385-602-4872
801-540-9258
2-27-2025
1
R/UL
VED TLS 300C
4061
96
YES
YES
YES
YES
81
YES
1.5
YES
2
DSL
VED TLS 300C
6091
96
YES
YES
YES
YES
81
YES
2.3
YES
PASS PASS
BATTERY BACKUP FUNCTIONS PROPERLY
ABOVEGROUND STORAGE TANK
SETUP REPORT PRINTED
Digitally signed by STEVEN B MARTIN
cn=STEVEN B MARTIN, o=AES, c=US
Date: 2025.03.11 10:33:37 -07'00'
Reason: I am the author of this document

BILLING ADDRESS FACILITY ADDRESS
WORK ORDER # DATE:
CONTACT: DEQ ID#
APPLIED ENVIRONMENTAL SERVICES, L.C.
SEND PAYMENT TO : APPLIED ENVIRONMENTAL SERVICES
ALL TESTS WERE PERFORMED IN A PROFESSIONAL MANNER, AND WITHIN COMMON PRACTICES OF THE INDUSTRY.
DUE TO VARIABLES OF TIGHTNESS TESTING, THESE RESULTS CANNOT BE GUARANTEED. THERE ARE NO WARRANTIES.
EXPRESSED, WRITTEN, OR IMPLIED.
PO BOX 1073 BOUNTIFUL, UTAH 84011
.
PO#
801-540-9258
STATE FUEL NETWORK
PO BOX 141152
SALT LAKE CITY, UTAH 84141-1152
MONTEZUMA CREEK ELEMENTARY
BRETT GURNEY 246107 5000164 / 1172
25011 2-27-2025
MONITOR CERTIFICATION
275.00
SITES SHARE OF TRAVEL
108 MI @ 2.00 216.00
INSTALLED STATE SUPPLIED OPW 623 PV VALVE ON UNLEADED VENT
1 HR @ 70.00 70.00
561.00TOTAL DUE: