DERR-2025-003165

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 _________________________________
100 N MARIO CAPECCHI DR
SALT LAKE CITY, UT 84130
PETRO WEST
1
DSL
VRTLS350
15,236
120
13,712
2
JOSE CASILLAS
4/16/25
PRIMARY CHILDRENS HOSPITAL
100 N MARIO CAPECCHI DR
SALT LAKE CITY, UT 84130
PETRO WEST
1
DSL
VRTLS350
15,236
120
13,712
2
JOSE CASILLAS
4/16/25
PRIMARY CHILDRENS HOSPITAL
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 _______________________________________________
100 N MARIO CAPRECCHI DR
SALT LAKE CITY, UT 84130
PETRO WEST
DSL
JOSE CASILLAS
PRIMARY CHILDRENS HOSPITAL
4/16/25
T1 INT
DSL
T1 STP
100 N MARIO CAPRECCHI DR
SALT LAKE CITY, UT 84130
PETRO WEST
DSL
JOSE CASILLAS
PRIMARY CHILDRENS HOSPITAL
4/16/25
T1 INT
DSL
T1 STP
44 North 800 East  St George, UT 84770  [phone]  Fax [phone]
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:___________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
PRIMARY CHILDRENS HOSPITAL 4/16/25
100 N MARIO CAPECCHI DR Jose Casillas
SALT LAKE CITY, UT 84113 4E46F605
DSL
RED JACKET
BALL VALVE
50
.0310 ML
.0310 ML
0
2:00 PM
3:00 PM
1 HR
PASS
Line Test with Petro-Tite.
SEE FORM C9 FOR LEAK DETECTOR INFO
PRIMARY CHILDRENS HOSPITAL 4/16/25
100 N MARIO CAPECCHI DR Jose Casillas
SALT LAKE CITY, UT 84113 4E46F605
DSL
RED JACKET
BALL VALVE
50
.0310 ML
.0310 ML
0
2:00 PM
3:00 PM
1 HR
PASS
Line Test with Petro-Tite.
SEE FORM C9 FOR LEAK DETECTOR INFO