HomeMy WebLinkAboutDERR-2025-002921pei.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.
11100 S AUTOMALL DR
SANDY, UT 84070
PETRO WEST
U N L
1
19,757
119
OPW
JOSE CASILLAS
COSTCO 487
4/9/25
UNL
2
19,757
119
OPW
PRE
3
19,459
116
OPW
DSL
4
19,470
115
OPW
11100 S AUTOMALL DR
SANDY, UT 84070
PETRO WEST
U N L
1
19,757
119
OPW
JOSE CASILLAS
COSTCO 487
4/9/25
UNL
2
19,757
119
OPW
PRE
3
19,459
116
OPW
DSL
4
19,470
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 4/9/25
1 2 3 4
UNL UNL PRE ADD
VRTLS350 VRTLS350 VRTLS350 VRTLS350
19,757 19,757 19,459 1,514
119 119 116 47
✔✔✔✔
✔✔✔✔
✔✔✔✔
✔✔✔✔
✔✔✔✔
17,781 17,781 17,513 1,363
17,781 17,781 17,513 1,363
90 90 90 90
✔✔✔✔
✔✔✔✔
✔✔✔✔
✔✔✔✔
JOSE CASILLAS
COSTCO 487
11100 S AUTOMALL DR
SANDY, UT 84070
PETRO WEST 4/9/25
1 2 3 4
UNL UNL PRE ADD
VRTLS350 VRTLS350 VRTLS350 VRTLS350
19,757 19,757 19,459 1,514
119 119 116 47
4 4 4 4
4 4 4 4
4 4 4 4
4 4 4 4
4 4 4 4
17,781 17,781 17,513 1,363
17,781 17,781 17,513 1,363
90 90 90 90
4 4 4 4
4 4 4 4
4 4 4 4
4 4 4 4
JOSE CASILLAS
COSTCO 487
11100 S AUTOMALL DR
SANDY, UT 84070
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 4/9/25
5 6
DSL DSL ADD
VRTLS350 VRTLS350
19,470 1,514
115 48
✔✔
✔✔
✔✔
✔✔
✔✔
17,523 1,363
17,523 1,363
90 90
✔✔
✔✔
✔✔
✔✔
JOSE CASILLAS
COSTCO 487
11100 S AUTOMALL DR
SANDY, UT 84070
PETRO WEST 4/9/25
5 6
DSL DSL ADD
VRTLS350 VRTLS350
19,470 1,514
115 48
4 4
4 4
4 4
4 4
4 4
17,523 1,363
17,523 1,363
90 90
4 4
4 4
4 4
4 4
JOSE CASILLAS
COSTCO 487
11100 S AUTOMALL DR
SANDY, UT 84070
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 _________________________________
11100 S AUTOMALL DR
SANDY, UT 84070
PETRO WEST
1
UNL
VRTLS350
19,757
119
17,781 17,781 17,513 1,363
1 1 1 NA
JOSE CASILLAS
2 3 4
UNL PRE ADD
VRTLS350
119
19,757
VRTLS350
19,459
116
VRTLS350
1,514
47
4/9/25
COSTCO 487
11100 S AUTOMALL DR
SANDY, UT 84070
PETRO WEST
1
UNL
VRTLS350
19,757
119
17,781 17,781 17,513 1,363
1 1 1 NA
JOSE CASILLAS
2 3 4
UNL PRE ADD
VRTLS350
119
19,757
VRTLS350
19,459
116
VRTLS350
1,514
47
4/9/25
COSTCO 487
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 _________________________________
11100 S AUTOMALL DR
SANDY, UT 84070
PETRO WEST
5
DSL
VRTLS350
19,470
115
17,523 1,363
1 NA
JOSE CASILLAS
6
DSL ADD
VRTLS350
48
1,514
4/9/25
COSTCO 487
11100 S AUTOMALL DR
SANDY, UT 84070
PETRO WEST
5
DSL
VRTLS350
19,470
115
17,523 1,363
1 NA
JOSE CASILLAS
6
DSL ADD
VRTLS350
48
1,514
4/9/25
COSTCO 487
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 __________________________________
11100 S AUTOMALL
SANDY, UT 84070
PETRO WEST
1
UNL
VR
PLLD
1
JOSE CASILLAS
COSTCO 487
4/9/25
2
UNL
VR
3
PRE
VR
PLLD PLLD
4
ADD
FEPETRO
STPMLD
5
DSL
VR
PLLD
6
DSL ADD
VR
PLLD
27
12
.0230 ML
2
10
2
29 29 29 28 29
1 1 1 1
11100 S AUTOMALL
SANDY, UT 84070
PETRO WEST
1
UNL
VR
PLLD
1
JOSE CASILLAS
COSTCO 487
4/9/25
2
UNL
VR
3
PRE
VR
PLLD PLLD
4
ADD
FEPETRO
STPMLD
5
DSL
VR
PLLD
6
DSL ADD
VR
PLLD
27
12
.0230 ML
2
10
2
29 29 29 28 29
1 1 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 487
111000 S AUTOMALL DR
SANDY, UT 84070
PETRO WEST 4/9/25
1 2 3
EAST WEST KIOSK
✔✔✔
✔✔✔
✔✔✔
✔✔✔
✔✔✔
✔✔✔
✔✔✔
✔✔✔
✔✔✔
JOSE CASILLAS
COSTCO 487
111000 S AUTOMALL DR
SANDY, UT 84070
PETRO WEST 4/9/25
1 2 3
EAST WEST KIOSK
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
PE
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1
2
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 _______________________________________________
11100 S AUTOMALL DR
SANDY, UT 84070
PETRO WEST
UNL
JOSE CASILLAS
COSTCO 487
4/9/25
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
11100 S AUTOMALL DR
SANDY, UT 84070
PETRO WEST
UNL
JOSE CASILLAS
COSTCO 487
4/9/25
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
PE
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1
2
0
0
-
1
9
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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 _______________________________________________
11100 S AUTOMALL DR
SANDY, UT 84070
PETRO WEST
PRE
JOSE CASILLAS
COSTCO 487
4/9/25
PRE STP DSL INT DSL FILL DSL STP DSL AD INT DSL AD STP
PRE DSL DSL DSL ADD ADD
PRE FILL
11100 S AUTOMALL DR
SANDY, UT 84070
PETRO WEST
PRE
JOSE CASILLAS
COSTCO 487
4/9/25
PRE STP DSL INT DSL FILL DSL STP DSL AD INT DSL AD STP
PRE DSL DSL DSL ADD ADD
PRE FILL
PE
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0
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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 _______________________________________________
11100 S AUTOMALL DR
SANDY, UT 84070
PETRO WEST
ADD
JOSE CASILLAS
COSTCO 487
4/9/25
ADD STP DIS 1/2 DIS 3/4 DIS 5/6 DIS 7/8 DIS 9/10
ADD UNLPREDSL UNLPREDSLUNLPREDSLUNLPREDSLUNLPREDSL
ADD INT
11100 S AUTOMALL DR
SANDY, UT 84070
PETRO WEST
ADD
JOSE CASILLAS
COSTCO 487
4/9/25
ADD STP DIS 1/2 DIS 3/4 DIS 5/6 DIS 7/8 DIS 9/10
ADD UNLPREDSL UNLPREDSL UNLPREDSL UNLPREDSL UNLPREDSL
ADD INT
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 _______________________________________________
11100 S AUTOMALL DR
SANDY, UT 84070
PETRO WEST
ADD
JOSE CASILLAS
COSTCO 487
4/9/25
DIS 13/14 DIS 15/16 DIS 17/18 VAPR SUMP
ADD UNLPREDSL UNLPREDSLVAPOR
DIS 11/12
11100 S AUTOMALL DR
SANDY, UT 84070
PETRO WEST
ADD
JOSE CASILLAS
COSTCO 487
4/9/25
DIS 13/14 DIS 15/16 DIS 17/18 VAPR SUMP
ADD UNLPREDSL UNLPREDSL VAPOR
DIS 11/12
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 487 4/9/25
11100 S AUTOMALL DR Jose Casillas
SANDY, UT 84070 4E46F605
UNL UNL PRE ADD
FEPETRO FEPETRO FEPETRO FEPETRO
BALL VALVE BALL VALVE BALL VALVE BALL VALVE
50 50 50 50
.0390 ML .0230 ML .0410 ML .0350 ML
.0390 ML .0230 ML .0410 ML .0350 ML
0 0 0 0
11:30PM 11:30 PM 1:10 AM 2:30 AM
12:30 AM 12:30 AM 2:10 AM 3:30 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
COSTCO 487 4/9/25
11100 S AUTOMALL DR Jose Casillas
SANDY, UT 84070 4E46F605
UNL UNL PRE ADD
FEPETRO FEPETRO FEPETRO FEPETRO
BALL VALVE BALL VALVE BALL VALVE BALL VALVE
50 50 50 50
.0390 ML .0230 ML .0410 ML .0350 ML
.0390 ML .0230 ML .0410 ML .0350 ML
0 0 0 0
11:30PM 11:30 PM 1:10 AM 2:30 AM
12:30 AM 12:30 AM 2:10 AM 3:30 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
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 487 4/9/25
11100 S AUTOMALL DR Jose Casillas
SANDY, UT 84070 4E46F605
DSL DSL ADD
FEPETRO FEPETRO
BALL VALVE BALL VALVE
50 50
.0510 ML .0260 ML .
.0510 ML .0260 ML .
0 0
10:00 PM 3:00 AM
11:00 PM 4:00 AM
1 HR 1 HR
PASS PASS
Line Test with Petro-Tite.
SEE FORM C9 FOR LEAK DETECTOR INFORMATION
COSTCO 487 4/9/25
11100 S AUTOMALL DR Jose Casillas
SANDY, UT 84070 4E46F605
DSL DSL ADD
FEPETRO FEPETRO
BALL VALVE BALL VALVE
50 50
.0510 ML .0260 ML .
.0510 ML .0260 ML .
0 0
10:00 PM 3:00 AM
11:00 PM 4:00 AM
1 HR 1 HR
PASS PASS
Line Test with Petro-Tite.
SEE FORM C9 FOR LEAK DETECTOR INFORMATION
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 487 4/9/25
11100 S AUTOMALL DR SANDY UT
Jose Casillas 4/9/25
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
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 487 4/9/25
11100 S Automall Dr Sandy 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
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: 4/9/25
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
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
4/9/25
Petro West
Jose Casillas
Jose Casillas 4/9/25
UnlPreDsl
1/2
Product
UnlPreDsl
3/4
Product
UnlPreDsl
5/6
Product
UnlPreDsl
7/8
Product
UnlPreDsl
9/10
Product
UnlPreDsl
11/12
Product
UnlPreDsl
13/14
Product
UnlPreDsl
15/16
Product
UnlPreDsl
17/18
Product
Costco 487
11100 S Auto Mall Dr
Sandy, UT 84070