HomeMy WebLinkAboutDERR-2025-002424pei.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.
13126 S EAGLE FIGHT RD
RIVERTON, UT 84096
PETRO WEST
U N L
1
39,647
117
OPW
JOSE CASILLAS
Costco 1441
3/13/25
UNL
2
39,647
117
OPW
PRE
3
39,837
117
OPW
13126 S EAGLE FIGHT RD
RIVERTON, UT 84096
PETRO WEST
U N L
1
39,647
117
OPW
JOSE CASILLAS
Costco 1441
3/13/25
UNL
2
39,647
117
OPW
PRE
3
39,837
117
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 3/13/25
1 2 3 4
UNL UNL PRE ADD
VRTLS450 VRTLS450 VRTLS450 VRTLS450
39,647 39,647 39,647 1514
117 117 117 47.5
✔✔✔✔
✔✔✔✔
✔✔✔✔
✔✔✔✔
✔✔✔✔
90 90 90 90
35,682 35,682 35,682 1363
90 90 90 90
✔✔✔✔
✔✔✔✔
✔✔✔✔
✔✔✔✔
JOSE CASILLAS
COSTCO 1441
13126 S EAGLES FLIGHT RD
RIVERTON, UT 84096
PETRO WEST 3/13/25
1 2 3 4
UNL UNL PRE ADD
VRTLS450 VRTLS450 VRTLS450 VRTLS450
39,647 39,647 39,647 1514
117 117 117 47.5
4 4 4 4
4 4 4 4
4 4 4 4
4 4 4 4
4 4 4 4
90 90 90 90
35,682 35,682 35,682 1363
90 90 90 90
4 4 4 4
4 4 4 4
4 4 4 4
4 4 4 4
JOSE CASILLAS
COSTCO 1441
13126 S EAGLES FLIGHT RD
RIVERTON, UT 84096
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 _________________________________
13126 S Eagles Flight Rd
Riverton, UT 84096
Petro West
1
Unl
VRTLS450
39,647
117
35,682 35,682 35,853 1363
1 in 1 in 1 in 1 in
Jose Casillas
2 3 4
Unl Pre Unl Add
VRTLS450
117
39,647
VRTLS450
39,837
117
VRTLS450
1514
47.5
3/13/25
Costco 1441
13126 S Eagles Flight Rd
Riverton, UT 84096
Petro West
1
Unl
VRTLS450
39,647
117
35,682 35,682 35,853 1363
1 in 1 in 1 in 1 in
Jose Casillas
2 3 4
Unl Pre Unl Add
VRTLS450
117
39,647
VRTLS450
39,837
117
VRTLS450
1514
47.5
3/13/25
Costco 1441
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 __________________________________
13126 S EAGLES FLIGHT RD
RIVERTON, UT 84096
PETRO WEST
1
UNL
VR
PLLD
1
JOSE CASILLAS
COSTCO 1441
3/13/25
2
UNL
VR
3
PRE
VR
PLLD PLLD
4
ADD
VR
PLLD
31 31 31 31
1 1 1
13126 S EAGLES FLIGHT RD
RIVERTON, UT 84096
PETRO WEST
1
UNL
VR
PLLD
1
JOSE CASILLAS
COSTCO 1441
3/13/25
2
UNL
VR
3
PRE
VR
PLLD PLLD
4
ADD
VR
PLLD
31 31 31 31
1 1 1
PE
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1
2
0
0
-
1
9
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AP
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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 _______________________________________________
13126 S Eagles Flight Rd
Riverton, UT 84096
Petro West
PRE
Jose Casillas
Costco 1441
3/13/25
PRE STP Dis 1/2 Dis 3/4 Dis 5/6 Dis 7/8 Dis 9/10
PRE UnlPre UnlPre UnlPre UnlPre UnlPre
PRE Fill
13126 S Eagles Flight Rd
Riverton, UT 84096
Petro West
PRE
Jose Casillas
Costco 1441
3/13/25
PRE STP Dis 1/2 Dis 3/4 Dis 5/6 Dis 7/8 Dis 9/10
PRE UnlPre UnlPre UnlPre UnlPre UnlPre
PRE Fill
PE
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1
2
0
0
-
1
9
pe
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AP
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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 _______________________________________________
13126 S Eagles Flight Rd
Riverton, UT 84096
Petro West
Add
Jose Casillas
Costco 1441
3/13/25
Add stp Add int Vent box Transitional Transitional
Add Add UnlPre UnlPre
Add fill
13126 S Eagles Flight Rd
Riverton, UT 84096
Petro West
Add
Jose Casillas
Costco 1441
3/13/25
Add stp Add int Vent box Transitional Transitional
Add Add UnlPre UnlPre
Add fill
PE
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1
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0
0
-
1
9
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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 _______________________________________________
13126 S Eagles Flight Rd
Riverton, UT 84096
Petro West
UnlPre
Jose Casillas
Costco 1441
3/13/25
Dis 13/14 Dis 15/16 Dis 17/18 Dis 19/20 Dis 21/22 Dis 23/24
UnlPre UnlPre UnlPre UnlPre UnlPre UnlPre
Dis 11/12
13126 S Eagles Flight Rd
Riverton, UT 84096
Petro West
UnlPre
Jose Casillas
Costco 1441
3/13/25
Dis 13/14 Dis 15/16 Dis 17/18 Dis 19/20 Dis 21/22 Dis 23/24
UnlPre UnlPre UnlPre UnlPre UnlPre UnlPre
Dis 11/12
PE
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1
2
0
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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 _______________________________________________
13126 S Eagles Flight Rd
Riverton, UT 84096
Petro West
UNL
Jose Casillas
Costco 1441
3/13/25
UNL A Fill UNL A STP UNL B Int UNL B Fill UNL B STP PRE Int
UNL UNL UNL UNL UNL PRE
UNL A Int
13126 S Eagles Flight Rd
Riverton, UT 84096
Petro West
UNL
Jose Casillas
Costco 1441
3/13/25
UNL A Fill UNL A STP UNL B Int UNL B Fill UNL B STP PRE Int
UNL UNL UNL UNL UNL PRE
UNL A Int
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 1441 3/13/25
13126 S EAGLES FLIGHT RD Jose Casillas
RIVERTON, UT 84096 4E46F605
UNL UNL PRE ADD
FEPETRO FEPETRO FEPETRO FEPETRO
BALL VALVE BALL VALVE BALL VALVE BALL VALVE
50 50 50 50
.0270 ML .0370 ML .0420 ML .0340 ML
.0270 ML .0370 ML .0420 ML .0340 ML
0 0 0 0
1:00. AM 11:15 PM 10:00 PM 3:00 AM
2:00 AM 12:15 AM 11:00 PM 4:00 AM
1 HR 1 HR 1 HR 1 HR
PASS PASS PASS PASS
Line Test with Petro-Tite. SEE FORM C9 FOR LEAK DETECTOR INFO
COSTCO 1441 3/13/25
13126 S EAGLES FLIGHT RD Jose Casillas
RIVERTON, UT 84096 4E46F605
UNL UNL PRE ADD
FEPETRO FEPETRO FEPETRO FEPETRO
BALL VALVE BALL VALVE BALL VALVE BALL VALVE
50 50 50 50
.0270 ML .0370 ML .0420 ML .0340 ML
.0270 ML .0370 ML .0420 ML .0340 ML
0 0 0 0
1:00. AM 11:15 PM 10:00 PM 3:00 AM
2:00 AM 12:15 AM 11:00 PM 4:00 AM
1 HR 1 HR 1 HR 1 HR
PASS PASS PASS PASS
Line Test with Petro-Tite. SEE FORM C9 FOR LEAK DETECTOR INFO
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 1441
13126 S EAGLES FLIGHT RD RIVERTON 84096
3/13/25 2:00 AM
4
OPW 623V
0 4
2.1 4
0 4
6.3 4
623V
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/DV9HJDV19 223KRQH 02 4 42)D[ 02 40DUFL+HQVRQ'LUHFWRU
!
COSTCO 1441
13126 S EAGLES FLIGHT RD RIVERTON 84096
3/13/25 11:35 PM
3/13/25 @ 3:25 PM
Dwyer mark III 475 7/24
UNL A UNL B PRE
35,000 35,000 35,000 105,000
4 IN 4 IN 4 IN
32,943 32,957 32,974 98,874
2,740 2,725 2,879 8,344
2.0
1.99
1.98
1.98
1.98
1.98
1.84
✔
TOTAL ULLAGE IS OVER ALLOWABLE. CANNOT TEST UNLESS TOTAL ULLAGE IS UNDER 25,000 GALLONS
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
3/13/25 Costco 1441
13126 S Eagles Flight Rd Riverton
OPW OPW OPW
61VS 61VS 61VS
Unl A Unl B Pre
27 23 17
27 23 17
27 23 17
27 23 17
OPW OPW OPW
61VS 61VS 61VS
Unl A Unl B Pre
25 14 19
25 14 19
25 14 19
25 14 19
Petro West Jose Casillas
3/13/25 Costco 1441
13126 S Eagles Flight Rd Riverton
OPW OPW OPW
61VS 61VS 61VS
Unl A Unl B Pre
27 23 17
27 23 17
27 23 17
27 23 17
OPW OPW OPW
61VS 61VS 61VS
Unl A Unl B Pre
25 14 19
25 14 19
25 14 19
25 14 19
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
3/13/25
Petro West
Jose Casillas
3/13/25
UnlPre
1/2
Product
UnlPre
3/4
Product
UnlPre
5/6
Product
UnlPre
7/8
Product
UnlPre
9/10
Product
UnlPre
11/12
Product
UnlPre
13/14
Product
UnlPre
15/16
Product
UnlPre
17/18
Product
Costco 1441
13126 S Eagle Flight Rd
Riverton, UT 84096
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
3/13/25
Petro West
Jose Casillas
3/13/25
UnlPre
19/20
Product
UnlPre
21/22
Product
UnlPre
23/24
Product
Costco 1441
13126 S Eagle Flight Rd
Riverton, UT 84096
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 1441 3/13/25
13126 S Eagle Flight Rd Riverton UT
Jose Casillas 3/13/25
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
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 1441 3/13/25
13126 S Eagle Flight Rd Petro West
Riverton, UT 84096 Jose Casillas
87A 87B Pre Add
Unl Unl Pre Add
5 in 7 in 6 in 5 in
Jose Casillas 3/13/25
4 4 4 4
4 4 4 4
4
4
4
4
4
4
4
4
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 1441 3/13/25
13126 S Eagles Flight Rd Riverton 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: 3/13/25
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 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
Functionality test reporting form and Drive Coupling replacement form
Site #
Site Address:
Test/Service Date:
Completed by:
Functionality Test conducted? ☐ Yes ☐ No
Suction at the Vapor inlet: ☐ Yes ☐ No
Air blowing out the Air Outlet: ☐ Yes ☐ No
No air blowing/suction at the Vapor Return: NORMAL ☐ Yes ☐ No
Motor Coupler Replaced? ☐ Yes ☐ No