DERR-2024-005665

VacuTect
Tank Tightness Test
page 1 of 1
Work Order:2364469 Date:3/14/2024
Site Name/ID:WALMART #WM5270
Address:629 N STATE ST
City:LINDON State:UT Zip:84042
Tank Information
Customer Tank ID
Regulatory Tank ID
Product Category
Product Name
Gallons Capacity
Tank Type
Tank Walls
Compartmentalized
Siphon Tank
Vents included with test
Test Start Time
Test End Time
Water ingress (Y/N)
Bubble ingress (Y/N)
Ullage ingress (Y/N)
Test Result (P/F/I)
1 RUL
1

Gasoline - Regular
RUL
19782
Fiberglass
Doublewall (factory)
No
Yes
with this tank
10:11:00
11:50:00
No
No
No
Pass
2 RUL 2
2

Gasoline - Regular
RUL 2
11904
Fiberglass
Doublewall (factory)
Yes
Yes
with this tank
10:11:00
11:50:00
No
No
No
Pass
3 PREMIUM
3

Gasoline - Premium
PREMIUM
7901
Fiberglass
Doublewall (factory)
Yes
No
with other tank
12:18:00
13:46:00
No
No
No
Pass
4 Low Sulfur Diesel
4

Diesel
Low Sulfur Diesel
10420
Fiberglass
Doublewall (factory)
No
No
with this tank
12:18:00
13:46:00
No
No
No
Pass

Yes - Test was performed per 3rd party certifications as specified in 40 CFR parts 280 and 281. No - diagnostic only

Technician Comments : UT151
Technician Name David Mathie Certification #41448 exp: 10/20/2025
Technician Signature

Environmental Compliance for Petroleum Systems
©2024 Tanknology Inc., Austin,TX. All rights reserved. tanknology.com
Product Line Tightness Test Page 1 of 1
Work Order: 2364469 Date: 3/14/2024
Site Name/ID: WALMART #WM5270 / WM5270
Address: 629 N STATE ST
City: LINDON State: UT Zip: 84042
Tank Information
Test Method
Customer Tank ID
Product Name
Delivery Type
Test Pressure (psi)
Test Start Time
Test End Time
Final Leak Rate (gph)
Test Result(P/F/I)
Test was performed per
3rd party certifications as
specified in 40 CFR parts
280 and 281
Tank # 1
Line # 1
TLD-1
1
RUL
Pressure
60
10:33
11:33
0.00
Pass
Yes
Tank # 2
Line # 1
TLD-1
2
RUL 2
Pressure
60
11:49
12:49
0.00
Pass
Yes
Tank # 3
Line # 1
TLD-1
3
PREMIUM
Pressure

10:33
11:33
0.00
Pass
Yes
Tank # 3
Line # 2
TLD-1
3
PREMIUM
Pressure
60
11:49
12:49
0.00
Pass
Yes
Tank # 4
Line # 1
TLD-1
4
Low Sulfur
Diesel
Pressure
60
10:33
11:33
0.00
Pass
Yes
Tank # 4
Line # 2
TLD-1
4
Low Sulfur
Diesel
Pressure
60
11:49
12:49
0.00
Pass
Yes
Technician Comments: UT151
Technician Name:David Mathie Certification #:41442 exp:
10/20/2025
Technician Signature:

Environmental Compliance for Petroleum Systems
©2024 Tanknology Inc., Austin, TX. All rights reserved. tanknology.com
WALMART #WM5270
629 N STATE ST
LINDON UT 84042
WM5270
Tanknology, Inc.
SAM'S CLUB
2001 S.E. 10TH STREET DEPT. # 449562
BENTONVILLE AR 72716
479-204-3407
03/14/2024
RUL RUL 2 Low Sulfur
DieselVeeder Root
DPLLD
Veeder Root
DPLLD
Veeder Root
DPLLD
Veeder Root
DPLLDDPLLDDPPLDDPLLDDPLLD
40
2
40
2 2
30 32
2
UT151
David Mathie
NW1-2364469
PREMIUM
T1:1 T2:1 T3:1 T4:1
Impact Valve
Inspection
Impact Valve Operational
Inspection
Work Order:2364469 Date:3/14/2024
Site Name/ID:WALMART #WM5270
Address:629 N STATE ST
City:LINDON State:UT Zip:84042
How Inspected: Line Test NFPA 30A PEI RP1200 Other
Dispenser
Number Grade
Secure
Mount?
Valve
Lock?Pass/ Fail Comments
1/2 40 Pass Fail Not Tested
1/2 85 Pass Fail Not Tested
1/2 91 Pass Fail Not Tested
3/4 85 Pass Fail Not Tested
3/4 91 Pass Fail Not Tested
5/6 85 Pass Fail Not Tested
5/6 91 Pass Fail Not Tested
7/8 40 Pass Fail Not Tested
7/8 85 Pass Fail Not Tested
7/8 91 Pass Fail Not Tested
9/10 40 Pass Fail Not Tested
9/10 85 Pass Fail Not Tested
9/10 91 Pass Fail Not Tested
11/12 85 Pass Fail Not Tested
11/12 91 Pass Fail Not Tested
13/14 85 Pass Fail Not Tested
13/14 91 Pass Fail Not Tested
15/16 40 Pass Fail Not Tested
15/16 85 Pass Fail Not Tested
15/16 91 Pass Fail Not Tested

Technician Comments:
Technician Name:David Mathie
Signature:
Environmental Compliance for Petroleum Systems
©2024 Tanknology Inc., Austin, TX. All rights reserved. tanknology.com
WALMART #WM5270 SAM'S CLUB
629 N STATE ST
LINDON UT 84042
WM5270
Tanknology, Inc.
2001 S.E. 10TH STREET DEPT. # 449562
BENTONVILLE AR 72716
479-204-3407
800-964-1250 03/14/2024
1 2 3 4
RUL RUL2 PREM DSL
VR450 PLUS VR450 PLUS VR450 PLUS VR450 PLUS
19782 11904 7901 10420
119.4 119.4 119.4 119.4
UT151
David Mathie
629 N STATE ST
WALMART #WM5270
629 N STATE ST, LINDON, UT 84042
WM5270
Tanknology, Inc.
SAM'S CLUB
2001 S.E. 10TH STREET DEPT. # 449562
BENTONVILLE, AR 72716
479-204-3407
03/14/2024
ANNULAR ANNULAR ANNULAR STP STP STP STP
RUL RUL2/PREM DSL RUL RUL2 PREM DSL
UT151
David Mathie
629 N STATE ST
WALMART #WM5270
629 N STATE ST, LINDON, UT 84042
WM5270
Tanknology, Inc.
SAM'S CLUB
2001 S.E. 10TH STREET DEPT. # 449562
BENTONVILLE, AR 72716
479-204-3407
03/14/2024
UDC UDC UDC UDC UDC UDC UDC
1/2 3/4 5/6 7/8 9/10 11/12 13/14
UT151
David Mathie
629 N STATE ST
WALMART #WM5270
629 N STATE ST, LINDON, UT 84042
WM5270
Tanknology, Inc.
SAM'S CLUB
2001 S.E. 10TH STREET DEPT. # 449562
BENTONVILLE, AR 72716
479-204-3407
03/14/2024
UDC
15/16
UT151
David Mathie
2 inch Pressure Decay Test
TP201.3

Store Information Testing Company
Site Name :WALMART #WM5270 Name :TANKNOLOGY INC.
Address :629 N STATE ST
LINDON, UT 84042
Address :11000 N. MoPac Expressway Suite 500
Austin, TX 78759
Phone :-Phone :[phone]

Stage I System?DUAL
Stage II System?NONE
Total # of Nozzles :16
Products per Nozzle :3
Tanks Manifolded ?Yes
Drop-Out tank present?NO
Total # of Tanks Tested :3

Tank Information :
Product Grade :
Tank Capacity, gallons :
Gasoline, gallons :
Ullage, gallons :
Testing Information :
Start Time :
Initial Pressure, wcg :
Pressure @ 1 minute(s) :
Pressure @ 2 minutes :
Pressure @ 3 minutes :
Pressure @ 4 minutes :
Pressure @ 5 minutes :
Allowable Final Pressure :
Pass/Fail (Enter "GF" Gross Failure)
1
RUL
19782
14929
4853

2
RUL 2
11904
7659
4245

3
PREMIUM
7901
4960
2941

14:49
2.00
2.00
1.99
1.99
1.98
1.98
1.92
Pass

Total

39587
27548
12039
All
14:49
2.00
2.00
1.99
1.99
1.98
1.98
1.92
Pass
Comments:

Tester :David Mathie Test Date :3/14/2024
Signature :Work Order :2364469

WO: 2364469
PVVC tested ==>GAS Manifolded
Final Test Result (Pass / Fail) ==>Pass
PVVC Manuf. ==>Husky Model Number ==>5885
Is this Original or
Replacement?
Original
If this cap is being
replaced, check here:
Manf Spec
(CFH)
Measured
Leak Rate
in ml/Min;
Cracking
(in H2O)
Calc CFH
(ml/min
x
.00212)
Result
(Pass /Fail)
Pos Leak Rate(CFH)0.05 9 0.0191 Pass
Low High Measured
Pos Cracking (in H2O)2.50 6.00 3.51 Pass
Neg Leak Rate (CFH)0.21 18 0.0382 Pass
Low High Measured
Neg Cracking (in H2O)-10.00 -6.00 -6.42 Pass
PVVC tested ==> Manifolded
Final Test Result (Pass / Fail) ==>
PVVC Manuf. ==>Model Number ==>
Is this Original or
Replacement?
Manf Spec
(CFH)
Measured
Leak Rate
in ml/Min;
Cracking
(in H2O)
Calc CFH
(ml/min
x
.00212)
Result
(Pass /Fail)
Pos Leak Rate(CFH)
Low High Measured
Pos Cracking (in H2O)
Neg Leak Rate (CFH)
Low High Measured
Neg Cracking (in H2O)
PVVC tested ==> Manifolded
Final Test Result (Pass / Fail) ==>
PVVC Manuf. ==>Model Number ==>
Is this Original or
Replacement?
Manf Spec
(CFH)
Measured
Leak Rate
in ml/Min;
Cracking
(in H2O)
Calc CFH
(ml/min
x
.00212)
Result
(Pass /Fail)
Pos Leak Rate(CFH)
Low High Measured
Pos Cracking (in H2O)
Neg Leak Rate (CFH)
Low High Measured
Neg Cracking (in H2O)
PVVC tested ==> Manifolded
Final Test Result (Pass / Fail) ==>
PVVC Manuf. ==>Model Number ==>
Is this Original or
Replacement?
Manf Spec
(CFH)
Measured
Leak Rate
in ml/Min;
Cracking
(in H2O)
Calc CFH
(ml/min
x
.00212)
Result
(Pass /Fail)
Pos Leak Rate(CFH)
Low High Measured
Pos Cracking (in H2O)
Neg Leak Rate (CFH)
Low High Measured
Neg Cracking (in H2O)
PVVC tested ==> Manifolded
Final Test Result (Pass / Fail) ==>
PVVC Manuf. ==>Model Number ==>
Is this Original or
Replacement?
Manf Spec
(CFH)
Measured
Leak Rate
in ml/Min;
Cracking
(in H2O)
Calc CFH
(ml/min
x
.00212)
Result
(Pass /Fail)
Pos Leak Rate(CFH)
Low High Measured
Pos Cracking (in H2O)
Neg Leak Rate (CFH)
Low High Measured
Neg Cracking (in H2O)
PVVC tested ==> Manifolded
Final Test Result (Pass / Fail) ==>
PVVC Manuf. ==>Model Number ==>
Is this Original or
Replacement?
Manf Spec
(CFH)
Measured
Leak Rate
in ml/Min;
Cracking
(in H2O)
Calc CFH
(ml/min
x
.00212)
Result
(Pass /Fail)
Pos Leak Rate(CFH)
Low High Measured
Pos Cracking (in H2O)
Neg Leak Rate (CFH)
Low High Measured
Neg Cracking (in H2O)
11000 N. MOPAC EXPRESSWAY, SUITE 500, AUSTIN, TX 78759
[phone]
QP-08-03-FF-02 Pressure Vacuum Vent Cap TP-201.1E Field Form
Rev C 1/27/2011
Site Overall Test Results: Pass
Total +ve LR: 0.0191
Total -ve LR: 0.0382

Test Date 3/14/2024
Technician Name David Mathie
WO #2364469
Facility Name / Loc #WALMART #WM5270 WM5270
Street 629 N STATE ST
City, St, Zip LINDON, UT 84042

Pressure Vacuum Vent Cap Test Form TP-201.1E

Stage I Vapor System Survey
Survey to determine compliance with Requirements of Title 40 Part 63 National Emission Standards for Hazardous Air Pollutants for Source Categories

Survey Date 3/14/2024 Work Order 2364469
Cust Name / Location Number WM5270
Street Address 629 N STATE ST
City, State, ZipCode LINDON UT 84042

Product
Stage I Type
Drop Tubes Type
Drop Tubes Max inches from tank Bottom
Fill Adapters Type
Vapor Adapters Type
NESHAP Work Required?

Vent Caps
Type
Labeled Positive Cracking Pressure
Labeled Negative Cracking Pressure
1
RUL
Dual Point
Straight w/ Flapper
6.00
Swivel
Swivel (poppet)
No

GAS
Pressure Vacuum cap
3
8
2
RUL 2
Dual Point
Straight w/ Flapper
5.00
Swivel
Swivel (poppet)
No

3
PREMIUM
Dual Point
Straight w/ Flapper
6.00
Swivel
Swivel (poppet)
No

Describe Work Required

Surveyed by Signature
WALMART #WM5270
629 N STATE ST
LINDON, UT 84042
WM5270
Tanknology, Inc.
SAM'S CLUB
479-204-3407
800-800-4633 03/14/2024
RUL
1
19782
118.375
OPW
RUL2
2
11904
118.375
OPW
PREM
3
7901
118.375
OPW
DSL
4
10420
118.375
OPW
UT151
David Mathie
2001 S.E. 10TH STREET
BENTONVILLE, AR 72716
64
161.75
10420
95.75
10420
9148
87.8
Site ID/ Name:
Address:
WM5270 WALMART #WM5270 NW1-2364469 03/14/2024
629 N STATE ST, LINDON, UT 84042
Tank ID:4(Low Sulfur Diesel)
62.75
164.25
11904
99.5
11904
10789
91
Site ID/ Name:
Address:
WM5270 WALMART #WM5270 NW1-2364469 03/14/2024
629 N STATE ST, LINDON, UT 84042
Tank ID:2(RUL 2)
63.25
162
7901
96.75
7901
6913
87.5
Site ID/ Name:
Address:
WM5270 WALMART #WM5270 NW1-2364469 03/14/2024
629 N STATE ST, LINDON, UT 84042
Tank ID:3(PREMIUM)
65.75
166.75
19782
99
19782
17781
89.4
Site ID/ Name:
Address:
WM5270 WALMART #WM5270 NW1-2364469 03/14/2024
629 N STATE ST, LINDON, UT 84042
Tank ID:1(RUL)
Tank ID:
Sam's Club Emergency Stop (E-Stop / ESO) Periodic Inspection
Facility Information Technician Information
Site #: WM5270 Date: 3/14/2024
Address: 629 N STATE ST Name: David Mathie
City / State: LINDON UT Technician Signature:
SITE DATA
1 Number of E-Stop switches INSIDE the building: 1
2 Number of E-Stop switches OUTSIDE the building: 2
3 Call Alarm Central at 479-273-4600
a.Press 1 for Alarm Central
b.Then press 4 for Technician
c.Tell the operator you want the Sam's Club / Wal-Mart Gas Station account for club membership WM5270 put on test.
d.They will ask for a password which is: 9350.
e.Record the Alarm Central persons name and the time that you spoke to them(Pre Alarm) NOT 11:00:00
PERFORMANCE DATA Yes No NA
4 You have added or confirmed that all E-Stop locations are on the Site Diagram
5 Do all E-Stops shutdown power to ALL DISPENSERS
6 Do all E-Stops shutdown power to ALL STP's
7 Are ALL E-Stops clearly Labeled
8 Are the TURBINE BREAKERS clearly identified / labeled
POST TEST
9 All equipment secured and any access ports, lids, enclosures are closed.
10 All safety barricades and test equipment has been properly removed
11 E-Stop was reset and all dispensing functions are normal
12 Call Alarm Central at 479-273-4600
a.Ask if Alarm was Received and if Yes, advise that testing is complete
b.Record the Alarm Central persons name and the time that you spoke to them(Post Alarm)
E-Stop Inspection Results
PASS FAIL INCONCLUSIVE
Comments
ESTOP OUTSIDE BY DOOR TO KIOSK
NOT CONNECTED TO ALARM CENTRAL YET

WO: 2364469
ANNUAL CONTAINMENT SUMP INSPECTION
This form may be utilized to document the inspection of containment sumps.
Date of Inspection
3/14/2024
UST Facility Person Conducting Test
Facility Name
WALMART #WM5270
Facility ID #
WM5270
Tester's Name
DMATHIE
Physical Address
629 N STATE ST
Company
Tanknology Inc.
City
LINDON
County
UTAH
State
UT
Certification #
41442
Expiration Date
10/20/2025
UST Owner
SAM'S CLUB
Tester's Signature Date
3/14/2024
Containment Sump Inspection
Sump Material
of Construction Fiberglass Reinforced Plastic Thermoplastic Steel Composite
Containment Sump Inspection Procedure
1. Clean-out and properly dispose of all debris, soil and/or fluids from the containment sump.
2. Visually examine the containment sump to ensure there are no cracks, holes, deteriorated seals, deformation or other
indications that the sump is not liquid tight.
3. If the sump appears to be liquid tight and no water was in the sump, the inspection result is "pass" and no further
action is required.
4. If the sump appears to be liquid tight but water was present within the sump, the inspection result is "fail".
5. If there is visual evidence that the sump is not liquid tight, then repair or replacement (see note below) of the sump is
required.
Inspection Results for the Year 2024
Sump ID
(product stored for STP or
dispenser number)
Sump lid/gasket in good
condition (yes/no)
Sump is dry (yes/no)
All penetration fittings in
good condition (yes/no)
Sump walls/bottom in
good condition (yes/no)
Are there any leaks from
pipe components (yes/no)
Inspection Result
(Pass/Fail)
STP:1 RUL - 1
Y
Y
Y
Y
N
Pass
STP:2 RUL 2 - 1
Y
Y
Y
Y
N
Pass
STP:3 PREMIUM - 1
Y
Y
Y
Y
N
Pass
STP:4 Low Sulfur Diesel -
1
Y
Y
Y
Y
N
Pass
Comments:

WO: 2364469
Site Diagram
(This site diagram is for reference only and is not drawn to scale)

Work Order:2364469
Site ID / Name:WM5270 / WALMART #WM5270
Address:629 N STATE ST
City:LINDON State:UT Zip:84042
W.O.# NW1-2364469 Cust Ref#: 38227303
OVF
WALMART #WM5270
629 N STATE ST
LINDON UT 84042
WM5270
Tanknology, Inc.
SAM'S CLUB
2001 S.E. 10TH STREET DEPT. # 449562
BENTONVILLE AR 72716
479-204-3407
12/14/2023
FRP
45
22
32
1246
32
1346
1 HR
0
FRP
45
21
31
1246
31
1346
1 HR
0
FRP
43
24
31
1246
31
1346
1 HR
0
FRP
43
24
30
1246
30
1346
1 HR
0
Tank 1 STP Sump
1
Tank 2 STP Sump
1
Tank 3 STP Sump
1
Tank 4 STP Sump
1
UT151
David Mathie
NW1-2364464
WALMART #WM5270
629 N STATE ST
LINDON UT 84042
WM5270
Tanknology, Inc.
SAM'S CLUB
2001 S.E. 10TH STREET DEPT. # 449562
BENTONVILLE AR 72716
479-204-3407
12/14/2023
FRP
16.5
7
11
1259
11
1359
1 HR
0
FRP
16.5
7
11
1259
11
1359
1 HR
0
FRP
16.5
7
11
1259
11
1359
1 HR
0
FRP
16.5
7
11
1259
11
1359
1 HR
0
FRP
16.5
7
11
1259
11
1359
1 HR
0
1/2 3/4 5/6 7/8 9/10 11/12
FRP
16.5
7
11
1259
11
1359
1 HR
0
UT151
David Mathie
NW1-2364464
WALMART #WM5270
629 N STATE ST
LINDON UT 84042
WM5270
Tanknology, Inc.
SAM'S CLUB
2001 S.E. 10TH STREET DEPT. # 449562
BENTONVILLE AR 72716
479-204-3407
12/14/2023
FRP
16.5
7
11
1259
11
1359
1 HR
0
FRP
16.5
7
11
1259
11
1359
1 HR
0
13/14 15/16
UT151
David Mathie
NW1-2364464
WALMART #WM5270
629 N STATE ST
LINDON, UT 84042
WM5270
Tanknology, Inc.
SAM'S CLUB
479-204-3407
12/14/2023
2001 S.E. 10TH STREET DEPT. # 449562
BENTONVILLE, AR 72716
1
RUL
5
OPW
2
RUL2
5
OPW
3
PREM
5
OPW
4
DSL
5
OPW
15 WC
1303
15 WC
1308
5 MIN
0
15 WC
1312
15 WC
1317
5 MIN
0
15 WC
1321
15 WC
1326
5 MIN
0
15 WC
1350
15 WC
1355
5 MIN
0
UT151
David Mathie
W.O.# NW1-2364464 Cust Ref#: 38227303
ANN
W.O.# NW1-2364464 Cust Ref#: 38227303
LINE
W.O.# NW1-2364464 Cust Ref#: 38227303
OVF
Underground Storage Tank Inspection Verification Form
Facility ID:1000995
Owner Name:WALMART INC.Facility Name:WALMART SUPERCENTER FUELING STATION #
Owner Address:2101 SE SIMPLE SAVINGS DR Street Address:585 NORTH STATE STREET
BENTONVILLE, AR 72716 LINDON, UT 84042
Operator A:SUZANNE NEVES / [phone] / 1/19/2027 Operator B:CAROLYN AGNITA JONES / [phone] /
1/19/2027
Owner Email:[e-mail] UTM Coordinates X/Y:437849 / 4466690
Disp ID/Alt
ID
Substance UDC Pipe Flex Loc Install Date UDC Install Date Fire
Valve
Sat
Present
UDC Test Disp Flex CP
Test
1 - 1/2 Gas/Diesel Yes Direct Flex Piping in
Sump no Steel Flex
12/12/2023 12/12/2023 Yes No 12/14/2023
2 - 3/4 Gas/Diesel Yes Direct Flex Piping in
Sump no Steel Flex
12/12/2023 12/12/2023 Yes No 12/14/2023
3 - 5/6 Gasoline Yes Direct Flex Piping in
Sump no Steel Flex
12/12/2023 12/12/2023 Yes No 12/14/2023
4 - 7/8 Gasoline Yes Direct Flex Piping in
Sump no Steel Flex
12/12/2023 12/12/2023 Yes No 12/14/2023
5 - 9/10 Gasoline Yes Direct Flex Piping in
Sump no Steel Flex
12/12/2023 12/12/2023 Yes No 12/14/2023
6 - 11/12 Gasoline Yes Direct Flex Piping in
Sump no Steel Flex
12/12/2023 12/12/2023 Yes No 12/14/2023
7 - 13/14 Gas/Diesel Yes Direct Flex Piping in
Sump no Steel Flex
12/12/2023 12/12/2023 Yes No 12/14/2023
8 - 15/16 Gas/Diesel Yes Direct Flex Piping in
Sump no Steel Flex
12/12/2023 12/12/2023 Yes No 12/14/2023
Tank ID/Alt ID:1 / 1 EGen/AST/Stat
e:
No / No / No Pipe Material-Mod:Flexible Plastic - Double-Walled
Siphon/Compart:No / No PVV/StageI:Yes Pipe Type/STP Cont:Pressurized / No
Tank Status:Currently In Use Two point STP Flex Connectors:Steel Flex in Sump
Installed/Cap/Loc:9/11/2023 / 20000 / LLD Model:
Substance Stored:Gasoline / Regular Spill/Overfill/Sm deliv:5 gal. Double Walled Spill Bucket / Automatic
shutoff / No
Tank Material-Mod:Fiberglass Reinforced Plastic - Double-Walled PST Fund/Other Type:Yes /
ATG:Veeder Root / TLS-450 Interstitial Monitor Tank/Pipe Rel Det:Interstitial DW / LTT / ALD
ATG Specs: / / Liquid Status STP Sump Test:12/14/2023 Spill Bk Test:
ATG Test:3/14/2024 Overfill Test:3/14/2024
LTT Test:3/14/2024 LLD Test:03/14/2024 CP Tank Test:CP Pipe Test:
Tank ID/Alt ID:2 / 2a EGen/AST/Stat
e:
No / No / No Pipe Material-Mod:Flexible Plastic - Double-Walled
Siphon/Compart:No / Yes PVV/StageI:Yes Pipe Type/STP Cont:Pressurized / No
Tank Status:Currently In Use Two point STP Flex Connectors:Steel Flex in Sump
Installed/Cap/Loc:9/11/2023 / 12000 / LLD Model:
Substance Stored:Gasoline / Regular Spill/Overfill/Sm deliv:5 gal. Double Walled Spill Bucket / Automatic
shutoff / No
Tank Material-Mod:Fiberglass Reinforced Plastic - Double-Walled PST Fund/Other Type:No /
ATG:Veeder Root / TLS-450 Interstitial Monitor Tank/Pipe Rel Det:Interstitial DW / LTT / ALD
ATG Specs: / / Liquid Status STP Sump Test:12/14/2023 Spill Bk Test:
ATG Test:3/14/2024 Overfill Test:3/14/2024
LTT Test:3/14/2024 LLD Test:03/14/2024 CP Tank Test:CP Pipe Test:
Tank ID/Alt ID:3 / 2b EGen/AST/Stat
e:
No / No / No Pipe Material-Mod:Flexible Plastic - Double-Walled
Siphon/Compart:No / Yes PVV/StageI:Yes Pipe Type/STP Cont:Pressurized / No
Tank Status:Currently In Use Two point STP Flex Connectors:Steel Flex in Sump
Installed/Cap/Loc:9/11/2023 / 8000 / LLD Model:
Substance Stored:Gasoline / Premium Spill/Overfill/Sm deliv:5 gal. Double Walled Spill Bucket / Automatic
shutoff / No
Tank Material-Mod:Fiberglass Reinforced Plastic - Double-Walled PST Fund/Other Type:No /
3/25/2024 Page 1 of 2
ATG:Veeder Root / TLS-450 Interstitial Monitor Tank/Pipe Rel Det:Interstitial DW / LTT / ALD
ATG Specs: / / Liquid Status STP Sump Test:12/14/2023 Spill Bk Test:
ATG Test:3/14/2024 Overfill Test:3/14/2024
LTT Test:3/14/2024 LLD Test:03/14/2024 CP Tank Test:CP Pipe Test:
Tank ID/Alt ID:4 / 3 EGen/AST/Stat
e:
No / No / No Pipe Material-Mod:Flexible Plastic - Double-Walled
Siphon/Compart:No / No PVV/StageI:Yes Pipe Type/STP Cont:Pressurized / No
Tank Status:Currently In Use Two point STP Flex Connectors:Steel Flex in Sump
Installed/Cap/Loc:9/11/2023 / 10000 / LLD Model:
Substance Stored:Diesel / Diesel #1 Spill/Overfill/Sm deliv:5 gal. Double Walled Spill Bucket / Automatic
shutoff / No
Tank Material-Mod:Fiberglass Reinforced Plastic - PST Fund/Other Type:No /
ATG:Veeder Root / Tank/Pipe Rel Det:Interstitial DW / LTT / ALD
ATG Specs: / / STP Sump Test:12/14/2023 Spill Bk Test:
ATG Test:3/14/2024 Overfill Test:3/14/2024
LTT Test:3/14/2024 LLD Test:03/14/2024 CP Tank Test:CP Pipe Test:
3/25/2024 Page 2 of 2

Sara Gallien
Walmart Inc
2101 SE Simple Savings Dr
Bentonville, AR 72716

Re: Notice of approval to remove delivery prohibition tag
Walmart Supercenter Fueling Station #5270
585 North State Street, Lindon Utah 84042
#1000995

Dear Sara Gallien:

The Division of Environmental Response and Remediation has received all the
documentation necessary to issue the attached certificate of compliance for the 20,000-gallon
Regular, 12,000-gallon Regular, 8000-gallon Premium and 10,000-gallon Diesel tanks at this
facility. This notice satisfies the requirement for written authorization to remove the delivery
prohibition tags in accordance with Utah Admin. Code R311-206-8(6). Please remove and discard
any tags that were attached to the fill for these tanks during installation. If you have additional
questions, please contact the Project Manager identified on the red tag at [phone].

Sincerely,

Brent H. Everett, Director
Division of Environmental Response and Remediation

Enclosure(s): cert. of compliance

cc:
United States
Environmental Protection Agency
Washington, DC 20460
Approval expires 04/30/24
OMB No.2050-0068
Notification for Underground Storage Tanks
Implementing Agency Name And Address:IMPLEMENTING AGENCY USE ONLY
ID NUMBER:
DATE RECEIVED:
TYPE OF NOTIFICATION DATE ENTERED INTO COMPUTER:
…A. NEW FACILITY
OR ONE-TIME
NOTIFICATION
(previously deferred
system)
…B. AMENDED …C. CLOSURE OR
CHANGE-IN-
SERVICE
DATA ENTRY CLERK INITIALS:
OWNER WAS CONTACTED TO CLARIFY RESPONSES, COMMENTS:
_____ Number of tanks at facility
_____ Number of continuation sheets attached
What USTs Are Included?An UST system is defined as any one or
combination of tanks that is used to contain an accumulation of regulated
substances, and whose volume (including connected underground piping) is 10
percent or more beneath the ground. Regulated USTs store petroleum or
hazardous substances (see What Substances Are Covered below). This
includes UST systems with field-constructed tanks and airport hydrant fuel
distribution systems.
What Tanks Are Excluded From Notification (see § 280.10 and § 280.12)?
x Tanks removed from the ground before May 8, 1986;
x Farm or residential tanks of 1,100 gallons or less capacity storing motor fuel for
noncommercial purposes;
x Tanks storing heating oil for use on the premises where stored;
x Septic tanks;
x Certain pipeline facilities regulated under chapters 601 and 603 of Title 49;
x Surface impoundments, pits, ponds, or lagoons;
x Storm water or wastewater collection systems;
x Flow-through process tanks;
x Liquid traps or associated gathering lines directly related to oil or gas production
and gathering operations;
x Tanks on or above the floor of underground areas, such as basements or tunnels;
x Tanks with a capacity of 110 gallons or less;
x Wastewater treatment tank systems;
x UST systems containing radioactive material that are regulated under the Atomic
Energy Act of 1954;
x UST systems that are part of an emergency generator system at nuclear power
generation facilities regulated by the Nuclear Regulatory Commission under 10
CFR part 50.
What Substances Are Covered?The notification requirements apply to
USTs containing petroleum or certain hazardous substances. Petroleum
includes gasoline, used oil, diesel fuel, crude oil or any fraction thereof which is
liquid at standard conditions of temperature and pressure (60 degrees
Fahrenheit and 14.7 pounds per square inch absolute). Hazardous
substances are those found in Section 101 (14) of the Comprehensive
Environmental Response, Compensation and Liability Act of 1980, with the
exception of those substances regulated as hazardous waste under Subtitle C
of the Resource Conservation and Recovery Act.
When And Who To Notify?Owners who bring USTs into use after May 8,
1986 must submit this notification form to the implementing agency within 30
days of bringing the UST into use. If the implementing agency requires
notification of any amendments to the facility, send information to the
implementing agency immediately.
Penalties:Any owner who knowingly fails to notify or submits false
information shall be subject to a civil penalty not to exceed $16,000 for each
tank for which notification is not given or for which false information is given.
INSTRUCTIONS AND GENERAL INFORMATION
Please type or print in ink. Also, be sure you have signatures in ink
for sections VIII and XI. Complete a notification form for each location
containing underground storage tanks. If more than 5 tanks are
owned at this location, you may photocopy pages 3 through 6 and use
them for additional tanks.
The primary purpose of this notification form is to provide information
about the installation, existence, changes to, and closure of
underground storage tank systems (USTs) that store or have stored
petroleum or hazardous substances. The information you provide will
be based on reasonably available records, or in the absence of such
records, your knowledge or recollection.
Federal law requires UST owners to use this notification form for
all USTs storing regulated substances that are brought into use
after May 8, 1986, or USTs in the ground as of May 8, 1986 that
have stored regulated substances at any time since January 1,
1974. The information requested is required by Section 9002 of
the Solid Waste Disposal Act (SWDA), as amended.
Who Must Notify?40 CFR part 280, as amended, requires owners
of USTs that store regulated substances (unless exempted) to notify
implementing agencies of the existence of their USTs. Owner is
defined as:
x In the case of an UST in use on November 8, 1984, or brought into use
after that date, any person who owns an UST used for storage, use, or
dispensing of regulated substances; or
x In the case of an UST in use before November 8, 1984, but no longer in
use on that date, any person who owned the UST immediately before its
discontinuation.
Also, owners of previously deferred UST systems with field-
constructed tanks and airport hydrant fuel distribution systems in the
ground as of October 13, 2015 must submit a one-time notification of
existence by October 13, 2018. Owners of UST systems with field-
constructed tanks and airport hydrant fuel distribution systems
brought into use after October 13, 2015 are considered new facilities
and must follow the same notification requirements as all other UST
owners.
I. OWNERSHIP OF USTs II. LOCATION OF USTs
Owner Name (Corporation, Individual, Public Agency, Or Other Entity)If required by implementing agency, give the geographic location of USTs either in decimal
degrees, or degrees, minutes, and seconds. Example: Latitude: 36.123480 (or 36q 7'
24.4"), Longitude: -106.549876 (or -106q 32' 59.6")
Latitude ________________ Longitude ________________
Street Address
County
Facility Name Or Company Site Identifier, As Applicable
… If address is the same as in Section I, check the box and proceed to section III.
If address is different, enter address below:
Street Address
County
City State Zip Code
Phone Number (Include Area Code) City State Zip Code
Utah Department of Environmental Quality, Division of Environmental Response
and Remediation
195 North 1950 West,Salt Lake City,Utah 84116
✔
4
Walmart, Inc.
40.348499 -111.731817
Walmart Fueling Station #52702101 SE Simple Savings Drive
Benton
Bentonville
479.258.2364 Lindon
AR
UT
72716
84042
629 N. State Street
Utah
EPA Form 7530-1 (Rev. 6-2015)Electronic and paper versions acceptable. Page 2 of 6
Previous editions may be used while supplies last.
United States
Environmental Protection Agency
Washington, DC 20460
Approval expires xx/xx/xx
OMB No.2050-0068
Notification For Underground Storage Tanks
III. TYPE OF OWNER IV. INDIAN COUNTRY
…Federal
Government
…State
Government
…Commercial
…Tribal
Government
…Local
Government
…Private
USTs are located on land within an
Indian reservation or on trust lands
outside reservation boundaries

Federally recognized tribe where USTs are
located:
V. TYPE OF FACILITY
…Auto Dealership …Federal – Military …Residential
…Commercial Airport Or Airline …Gas Station …Trucking Or Transport
…Contractor …Industrial …Utilities
…Farm …Petroleum Distributor …Other (Explain) ____________________
…Federal – Non-military …Railroad
VI. CONTACT PERSON IN CHARGE OF TANKS
Name:Job Title:Address:Phone Number (Include Area Code):
VII. FINANCIAL RESPONSIBILITY
…I have met the financial responsibility requirements (in accordance with 40 CFR part 280 Subpart H) by using the following mechanisms:
(check all that apply)
…Bond Rating Test …Local Government Financial Test …Surety Bond
…Commercial Insurance …Risk Retention Group …Trust Fund
…Guarantee …Self-insurance (Financial Test)…Other Method (describe here)
…Letter Of Credit …State Fund ___________________________
…I do not have to meet financial responsibility requirements because 40 CFR part 280 Subpart H is not applicable to me (e.g., if you are a state or
federal owner).
VIII. CERTIFICATION (Read and sign after completing ALL SECTIONS of this notification form)
I certify under penalty of law that I have personally examined and am familiar with the information submitted in Sections I through XI of this notification
form and all attached documents, and that based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that
the submitted information is true, accurate, and complete.
Name and official title of owner or owner’s
authorized representative (Print)
Signature Date Signed
Paperwork Reduction Act Notice
The public reporting and recordkeeping burden for this collection of information is estimated to average 30 minutes per response. Responses to this collection of information
are mandatory (40 CFR 280.22). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently
valid OMB control number. This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2050-
0068).
Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden,
including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200
Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.
✔
✔
Sara Gallien Fuel Compliance Manager 2101 SE Simple Savings Drive,
Bentonville, Arkansas, 72716
479.258.2364
✔
✔
William Bailor - APTIM Environmental & Infrastructure, LLC
as an agent for Walmart Inc.3/20/2024
EPA Form 7530-1 (Rev. 6-2015)Electronic and paper versions acceptable. Page 3 of 6
Previous editions may be used while supplies last.
United States
Environmental Protection Agency
Washington, DC 20460
Approval expires xx/xx/xx
OMB No.2050-0068
Notification For Underground Storage Tanks
IX. DESCRIPTION OF UNDERGROUND STORAGE TANKS (Complete for all tanks and piping at this location)
Tank Identification Number Tank No.Tank No. Tank No. Tank No. Tank No.
1. Status Of Tank (check only one)
Currently In Use
Temporarily Closed
Permanently Closed

2. Date Of Installation (month/year)
3. Estimated Total Capacity (gallons)
4. Tank Attributes
(check all that apply)
Asphalt Coated Or Bare Steel ……………
Cathodically Protected Steel
(impressed current)……………
Cathodically Protected Steel
(sacrificial anodes)……………
Coated and Cathodically Protected Steel
(impressed current)……………
Coated and Cathodically Protected Steel
(sacrificial anodes)……………
Composite
(steel clad with noncorrodible material)……………
Concrete ……………
Fiberglass Reinforced Plastic ……………
Noncorrodible Tank Jacket ……………
Lined Interior ……………
Excavation Liner ……………
Double Walled ……………
Manifolded ……………
Compartmentalized ……………
Field-constructed ……………
Double Walled ……………
Unknown ……………
Other, Specify Here ___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
Check Box If Tank Has Ever Been
Repaired ……………
5. Overfill Protection Installed
(check all that apply)
Automatic Shutoff ……………
Flow Restrictor ……………
High-level Alarm ……………
Other, Specify Here ___________ ___________ ___________ ___________ ___________
6. Spill Prevention Installed ……………
Double Walled ……………
T1
✔✔✔✔
11/09/2023 11/09/2023 11/09/2023 11/09/2023
20,000 12,000 8,000 10,000
✔✔✔✔
✔✔✔✔
✔✔
✔✔✔✔
✔✔✔✔
Flapper Valve Flapper Valve Flapper Valve Flapper Valve
✔✔✔✔
✔✔✔✔
EPA Form 7530-1 (Rev. 6-2015)Electronic and paper versions acceptable. Page 4 of 6
Previous editions may be used while supplies last.
United States
Environmental Protection Agency
Washington, DC 20460
Approval expires xx/xx/xx
OMB No.2050-0068
Notification For Underground Storage Tanks
Tank Identification Number Tank No.Tank No. Tank No. Tank No. Tank No.
7. Piping Attributes
(check all that apply)
Bare Steel ……………
Galvanized Steel ……………
Fiberglass Reinforced Plastic ……………
Flexible Plastic ……………
Copper ……………
Cathodically Protected
(impressed current)……………
Cathodically Protected
(sacrificial anodes)……………
Double Walled ……………
Secondary Containment ……………
Airport Hydrant Piping ……………
Unknown ……………
Other, Specify Here
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
8. Piping Delivery Type
(check all that apply)
Safe Suction (no valve at tank)……………
U.S. Suction (valve at tank)……………
Pressure ……………
Gravity Feed ……………
9. Substance Currently Stored (or last
stored in the case of closed tanks)
(check all that apply)
*DVROLQHFRQWDLQLQJ”HWKDQRO……………
Diesel ……………
Biodiesel ……………
Kerosene ……………
Heating Oil ……………
Used Oil ……………
*DVROLQH&RQWDLQLQJ!(thanol
(specify amount of ethanol)
___________ ___________ ___________ ___________ ___________
'LHVHO&RQWDLQLQJ!%iodiesel
(specify amount of biodiesel)
___________ ___________ ___________ ___________ ___________
Other, specify here ___________ ___________ ___________ ___________ ___________
Hazardous Substance ……………
CERCLA Name Or CAS Number ___________ ___________ ___________ ___________ ___________
Mixture Of Substances ……………
Please Specify Substances Here ___________ ___________ ___________ ___________ ___________
✔✔✔✔
✔✔✔✔
✔✔✔✔
✔✔✔
✔
EPA Form 7530-1 (Rev. 6-2015)Electronic and paper versions acceptable. Page 5 of 6
Previous editions may be used while supplies last.
United States
Environmental Protection Agency
Washington, DC 20460
Approval expires xx/xx/xx
OMB No.2050-0068
Notification For Underground Storage Tanks
Tank Identification Number Tank No.Tank No. Tank No. Tank No. Tank No.
10. Release Detection
(check all that apply) TANK PIPE TANK PIPE TANK PIPE TANK PIPE TANK PIPE
Manual Tank Gauging ……………
Tank Tightness Testing ……………
Inventory Control ……………
Automatic Tank Gauging …………………………
Vapor Monitoring …………………………
Groundwater Monitoring …………………………
Interstitial Monitoring
(required for new or replaced
tanks or piping)

Statistical Inventory Reconciliation …………………………
Automatic Line Leak Detectors ……………
Line Tightness Testing ……………
No Release Detection Required
(such as some types of suction piping)…………………………
Other Method Allowed By Implementing
Agency …………………………
Other, Specify Here ___________ ___________ ___________ ___________ ___________
X. CLOSURE OR CHANGE IN SERVICE
1. Closure Or Change In Service
Estimated Date The UST Was Last Used
For Storing Regulated Substances
(month/day/year)
___________ ___________ ___________ ___________ ___________
Check Box If This Is A Change In
Service
(i.e., Change of storage to a non-
regulated substance)

2. Tank Closure
Estimated Date Tank Closed
(month/day/year)___________ ___________ ___________ ___________ ___________
(check all that apply below)
Tank Removed From Ground ……………
Tank Closed In Ground ……………
Tank Filled With Inert Material ……………
Describe The Inert Fill Material Here ___________ ___________ ___________ ___________ ___________
3. Site Assessment
Check Box If The Site Assessment Was
Completed ……………
Check Box If Evidence Of A Release
Was Detected ……………
Other, Specify Here ___________ ___________ ___________ ___________ ___________
✔✔✔✔
✔✔✔✔
✔✔✔✔
✔✔✔✔
✔✔✔✔
T1 T2 T3 T4
DD4
TYP OF 2
2
FST1 43
FL073FL058c
FUELING
POSITION
NUMBER TYP
65
FL044
TYP OF 8
FL058cFL073
1615
FL058eFL074
FST4
6
FL058eFL074
FL073FL058c FL058cFL073
87
1211 1413
SERVICE
BUILDING
FL060 FL061
TYP
21
FL074FL058a
109
SIDE
"B"
TYP
SIDE
"A"
TYP
FST4
1 TYP OF 4
TANK 1
UNLEADED
20,000
GALLONS
VERIFY DURING PIPING INSPECTION
THAT ALL TOPS OF MANHOLES ARE
SET AT CORRECT GRADE ELEVATION
TANK 3
SUPER UNLEADED
8,000 GALLONS
PRODUCT FILL
TO VENT RISER
REF CIVIL
DWGS FOR
LOCATION
TANK INTERSTITIAL
SPACE RISER
DIESEL VENT
CONNECTION
FL079
TYP
REF 7 - FST3
TYP
REF 6 - FST5
REF 3 - FST3
REF 3 - FST5
REF 1 - FST3TANK PROBE
REF 7 - FST5
REF 5 - FST5
3
FST21
FST2
OBSERVATION WELL
REF 2 - FST5
TANK INTERSTITIAL
SPACE RISER
TANK 2
UNLEADED 12,000
GALLONS
11.105
11.106
REF 2 - FST3
2
FST2
DIESEL PRODUCT FILL
TANK 4
DIESEL
10,000 GALLONS
EQUALIZATION PIPING
REF 9 - FST3
VAPOR
RECOVERY
CONNECTION
TYP
REF 4 - FST5
REF 1 - FST5
REF 1 - FST5
11.106
PRODUCT PIPING TO SLOPE A
MINIMUM OF 1/8" PER FOOT BETWEEN
TANKS AND FIRST DISPENSER
11.106
11.106
FL074FL058a
TYP OF 2FST4
6
1/8" = 1'-0"
PIPING PLAN-3T1
1
N

195 North 1950 West • Salt Lake City, UT
Mailing Address: P.O. Box 144840 • Salt Lake City, UT 84114-4840
Telephone [phone] • Fax [phone] • T.D.D. [phone]
www.deq.utah.gov
Printed on 100% recycled paper
State of Utah

SPENCER J. COX
Governor

DEIDRE HENDERSON
Lieutenant Governor
Department of
Environmental Quality

Kimberly D. Shelley
Executive Director

DIVISION OF ENVIRONMENTAL
RESPONSE AND REMEDIATION

Brent H. Everett
Director
ERRP-130-24

March 28, 2024

Sara Gallien
Walmart, Inc.
2101 Southeast Simple Savings Drive
Bentonville, Arkansas 72716

Re: Notice of Approval to Remove Delivery Prohibition Tag
Walmart Supercenter Fueling Station #5270
Located at 585 North State Street, Lindon, Utah
Facility Identification No. 1000995

Dear Ms. Gallien:

The Division of Environmental Response and Remediation (DERR) has received all the
documentation necessary to issue the attached certificate of compliance for the 20,000-gallon
regular, 12,000-gallon regular, 8,000-gallon premium, and 10,000-gallon diesel tanks at this facility.
This notice satisfies the requirement for written authorization to remove the delivery prohibition
tags in accordance with Utah Admin. Code R311-206-8(6). Please remove and discard any tags that
were attached to the fill for these tanks during installation. If you have additional questions, please
contact the DERR project manager, identified on the red tag, at [phone].

Sincerely,

Brent H. Everett, Director
Division of Environmental Response and Remediation

BHE/LP/ss

Enclosure: Certificate of Compliance

cc: Eric Edwards, Executive Director, Utah County Health Department
UST Red Tag Removal Letter – CoC Issuance Sign-Off Sheet
ERRU#____________
Author
Subject
File Name on Google Drive
Enclosures
Attached CoC
Attached Tank Data
Sheet(internal use only – do
not mail)
Payment of Fees Confirmed?
Priority
CC’s
Special Instructions
Draft Approval Process
Project Manager
Section Manager
Final Approval Process
Section Secretary
Author
Branch Secretary
Administrative Secretary
Section Secretary
Scan #
Certified Mail
Enclosures Included
CC’s Mailed
Mailed By
LP
LP
CoC
Tank Data Sheet
Rush
03/26/2024
Yes
Red Tag Removal
Yes
1000995 Red Tag Removal Walmart Lindon
Laura Perdue
03/2ц/2024
03/2ц/2024
SS
130-24
03/2ч/2024
LP
LP 03/2ч/2024
SS
03/2ч/2024
03/2ч/2024
2024
UST CERTIFICATE
OF
COMPLIANCE
ISSUED TO:LOCATION OF TANKS:
SARA GALLIEN WALMART SUPERCENTER FUELING
STATION #5270
WALMART INC.585 NORTH STATE STREET
2101 SE SIMPLE SAVINGS DR LINDON UT 84042
BENTONVILLE, AR 72716 Facility ID: 1000995
Tank #Capacity Substance Desc Compliance Financial Assurance Mechanism
1 20000 Gasoline Yes PST Fund
2a 12000 Gasoline Yes PST Fund
2b 8000 Gasoline Yes PST Fund
3 10000 Diesel Yes PST Fund
This certificate will automatically lapse if any of the required fees are not paid. It may also be revoked for failure to
comply with state and federal UST regulations. Possession of this certificate does not signify coverage under the Utah
PST Fund. Cleanup requirements may be obtained from the Division of Environmental Response and Remediation.
UTAH DEPARTMENT OF ENVIRONMENTAL QUALITY
2 inch Pressure Decay Test
TP201.3

Store Information Testing Company
Site Name :WALMART #WM5270 Name :TANKNOLOGY INC.
Address :629 N STATE ST
LINDON, UT 84042
Address :11000 N. MoPac Expressway Suite 500
Austin, TX 78759
Phone :-Phone :[phone]

Stage I System?DUAL
Stage II System?NONE
Total # of Nozzles :16
Products per Nozzle :3
Tanks Manifolded ?Yes
Drop-Out tank present?NO
Total # of Tanks Tested :3

Tank Information :
Product Grade :
Tank Capacity, gallons :
Gasoline, gallons :
Ullage, gallons :
Testing Information :
Start Time :
Initial Pressure, wcg :
Pressure @ 1 minute(s) :
Pressure @ 2 minutes :
Pressure @ 3 minutes :
Pressure @ 4 minutes :
Pressure @ 5 minutes :
Allowable Final Pressure :
Pass/Fail (Enter "GF" Gross Failure)
1
RUL
19782
14929
4853

2
RUL 2
11904
7659
4245

3
PREMIUM
7901
4960
2941

14:49
2.00
2.00
1.99
1.99
1.98
1.98
1.92
Pass

Total

39587
27548
12039
All
14:49
2.00
2.00
1.99
1.99
1.98
1.98
1.92
Pass
Comments:

Tester :David Mathie Test Date :3/14/2024
Signature :Work Order :2364469

WO: 2364469
PVVC tested ==>GAS Manifolded
Final Test Result (Pass / Fail) ==>Pass
PVVC Manuf. ==>Husky Model Number ==>5885
Is this Original or
Replacement?
Original
If this cap is being
replaced, check here:
Manf Spec
(CFH)
Measured
Leak Rate
in ml/Min;
Cracking
(in H2O)
Calc CFH
(ml/min
x
.00212)
Result
(Pass /Fail)
Pos Leak Rate(CFH)0.05 9 0.0191 Pass
Low High Measured
Pos Cracking (in H2O)2.50 6.00 3.51 Pass
Neg Leak Rate (CFH)0.21 18 0.0382 Pass
Low High Measured
Neg Cracking (in H2O)-10.00 -6.00 -6.42 Pass
PVVC tested ==> Manifolded
Final Test Result (Pass / Fail) ==>
PVVC Manuf. ==>Model Number ==>
Is this Original or
Replacement?
Manf Spec
(CFH)
Measured
Leak Rate
in ml/Min;
Cracking
(in H2O)
Calc CFH
(ml/min
x
.00212)
Result
(Pass /Fail)
Pos Leak Rate(CFH)
Low High Measured
Pos Cracking (in H2O)
Neg Leak Rate (CFH)
Low High Measured
Neg Cracking (in H2O)
PVVC tested ==> Manifolded
Final Test Result (Pass / Fail) ==>
PVVC Manuf. ==>Model Number ==>
Is this Original or
Replacement?
Manf Spec
(CFH)
Measured
Leak Rate
in ml/Min;
Cracking
(in H2O)
Calc CFH
(ml/min
x
.00212)
Result
(Pass /Fail)
Pos Leak Rate(CFH)
Low High Measured
Pos Cracking (in H2O)
Neg Leak Rate (CFH)
Low High Measured
Neg Cracking (in H2O)
PVVC tested ==> Manifolded
Final Test Result (Pass / Fail) ==>
PVVC Manuf. ==>Model Number ==>
Is this Original or
Replacement?
Manf Spec
(CFH)
Measured
Leak Rate
in ml/Min;
Cracking
(in H2O)
Calc CFH
(ml/min
x
.00212)
Result
(Pass /Fail)
Pos Leak Rate(CFH)
Low High Measured
Pos Cracking (in H2O)
Neg Leak Rate (CFH)
Low High Measured
Neg Cracking (in H2O)
PVVC tested ==> Manifolded
Final Test Result (Pass / Fail) ==>
PVVC Manuf. ==>Model Number ==>
Is this Original or
Replacement?
Manf Spec
(CFH)
Measured
Leak Rate
in ml/Min;
Cracking
(in H2O)
Calc CFH
(ml/min
x
.00212)
Result
(Pass /Fail)
Pos Leak Rate(CFH)
Low High Measured
Pos Cracking (in H2O)
Neg Leak Rate (CFH)
Low High Measured
Neg Cracking (in H2O)
PVVC tested ==> Manifolded
Final Test Result (Pass / Fail) ==>
PVVC Manuf. ==>Model Number ==>
Is this Original or
Replacement?
Manf Spec
(CFH)
Measured
Leak Rate
in ml/Min;
Cracking
(in H2O)
Calc CFH
(ml/min
x
.00212)
Result
(Pass /Fail)
Pos Leak Rate(CFH)
Low High Measured
Pos Cracking (in H2O)
Neg Leak Rate (CFH)
Low High Measured
Neg Cracking (in H2O)
11000 N. MOPAC EXPRESSWAY, SUITE 500, AUSTIN, TX 78759
[phone]
QP-08-03-FF-02 Pressure Vacuum Vent Cap TP-201.1E Field Form
Rev C 1/27/2011
Site Overall Test Results: Pass
Total +ve LR: 0.0191
Total -ve LR: 0.0382

Test Date 3/14/2024
Technician Name David Mathie
WO #2364469
Facility Name / Loc #WALMART #WM5270 WM5270
Street 629 N STATE ST
City, St, Zip LINDON, UT 84042

Pressure Vacuum Vent Cap Test Form TP-201.1E

ANNUAL CONTAINMENT SUMP INSPECTION
This form may be utilized to document the inspection of containment sumps.
Date of Inspection
3/14/2024
UST Facility Person Conducting Test
Facility Name
WALMART #WM5270
Facility ID #
WM5270
Tester's Name
DMATHIE
Physical Address
629 N STATE ST
Company
Tanknology Inc.
City
LINDON
County
UTAH
State
UT
Certification #
41442
Expiration Date
10/20/2025
UST Owner
SAM'S CLUB
Tester's Signature Date
3/14/2024
Containment Sump Inspection
Sump Material
of Construction Fiberglass Reinforced Plastic Thermoplastic Steel Composite
Containment Sump Inspection Procedure
1. Clean-out and properly dispose of all debris, soil and/or fluids from the containment sump.
2. Visually examine the containment sump to ensure there are no cracks, holes, deteriorated seals, deformation or other
indications that the sump is not liquid tight.
3. If the sump appears to be liquid tight and no water was in the sump, the inspection result is "pass" and no further
action is required.
4. If the sump appears to be liquid tight but water was present within the sump, the inspection result is "fail".
5. If there is visual evidence that the sump is not liquid tight, then repair or replacement (see note below) of the sump is
required.
Inspection Results for the Year 2024
Sump ID
(product stored for STP or
dispenser number)
Sump lid/gasket in good
condition (yes/no)
Sump is dry (yes/no)
All penetration fittings in
good condition (yes/no)
Sump walls/bottom in
good condition (yes/no)
Are there any leaks from
pipe components (yes/no)
Inspection Result
(Pass/Fail)
STP:1 RUL - 1
Y
Y
Y
Y
N
Pass
STP:2 RUL 2 - 1
Y
Y
Y
Y
N
Pass
STP:3 PREMIUM - 1
Y
Y
Y
Y
N
Pass
STP:4 Low Sulfur Diesel -
1
Y
Y
Y
Y
N
Pass
Comments:

WO: 2364469
PST Owner Information
Facility ID#
PST Facility Information
Owner Name: Facility Name:
Address: Address:
City: State: Zip: City: State: UT Zip:
Contact: Phone: Contact: Phone:
DESCRIPTION OF PETROLEUM STORAGE TANKS
Tank #
UST or AST
Date Installed
Capacity
Substance Stored
TANK/LINE TIGHTNESS TEST Indicate Pass or Fail for each tank and product line tested. Include a copy of the test.
Tank #
Tank Test
Line Test
TYPE OF FACILITY
Marketing facility, or non-marketer with facility average monthly throughput greater than 10,000 gallons.
Non-marketer with facility average monthly throughput less than 10,000 gallons.
COMPLIANCE WITH PST REGULATIONS
All Petroleum Storage Tanks (PSTs) at this facility have been registered.
Registration fees and Petroleum Storage Tank Fund Fees have been paid.
Are your PSTs currently in compliance with all Federal, State, and Local PST regulations, including applicable Fire Code?
Yes No If "No" describe items of non-compliance:
PREVIOUS POLLUTION INCIDENTS
Complete the Previous Pollution Incidents form to indicate whether a pollution incident has occurred at the facility.
FINANCIAL RESPONSIBILITY MECHANISM DECLARATION (check one only)
* Non-regulated PSTs at the facility may be required to participate in the Environmental Assurance Program.
I choose another Financial Responsibility mechanism for the PSTs at this facility.
•Indicate the financial responsibility mechanism to be used:
•(For self-insurance or guarantee) Indicate your company’s fiscal year end date:
•(For Insurance) Indicate the date the policy is renewed each year:
The Certificate of Compliance cannot be issued until all documents have been submitted and the mechanism has been approved. If
the mechanism has already been approved, submit documentation of coverage for the new tanks.
I certify under penalty of law that the above representations made by me are true and correct.
CofCapp 1022
Utah Petroleum Storage Tank Program
Application for Certificate of Compliance
I choose to participate in the Environmental Assurance Program (PST Fund) *.
•Indicate the financial responsibility mechanism to be used for cleanup costs not covered by the Fund.
•Indicate the number of non-regulated petroleum storage tanks at the facility.
Owner/operator Signature Date Signed
1000995
T1 T2 T3 T4 N/A N/A
UST UST UST UST
11/09/2023 11/09/2023 11/09/2023 11/09/2023
20,000 12,000 8,000 10,000
Reg. Unleaded Reg. Unleaded Super Unleaded Diesel
T1 T2 T3 T4 N/A N/A
PASS PASS PASS PASS
PASS PASS PASS PASS
4
4
4
4
4
Insurance
3/25/2024
Walmart Inc.
2101 SE Simple Savings Drive
Bentonville AR 72716
Sara Gallien 479.258.2364
Walmart Fueling Station #5270
629 North State Street
Lindon 84042
Anderson Alves 801.785.7863
4
0