DERR-2025-004172

Annual Sump Inspection
IMPACT VALVE
LEAK DETECTOR
Line Tightness Test
MONITOR CERTIFICATION
SPILL BUCKET TEST
STAGE I SURVEY
11000 N. MoPac Expressway, Suite 500
Austin, Texas 78759
Phone: [phone]
Fax: [phone] Date Printed and Mailed: 6/3/2025
UTAH DEPARTMENT OF ENV. QUALITY
UST
PO Box 144840
SALT LAKE CITY, UT 84114
Test Date: 5/29/2025
Order Number: 2380030
Dear Regulator,
Enclosed are the results of recent testing performed at the following facility:
Neighborhood Market #5109 (NM5109)
4570 S 4000 W
West Valley City, UT 84120
Testing performed:
Sincerely,
Dawn Kohlmeyer
Manager, Field Reporting
Product Line Tightness Test Page 1 of 1
Work Order: 2380030 Date: 5/29/2025
Site Name/ID: Neighborhood Market #5109 / NM5109
Address: 4570 S 4000 W
City: West Valley City State: UT Zip: 84120
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 WEST
RUL
Pressure
60
09:20
10:20
0.00
Pass
Yes
Tank # 2
Line # 1
TLD-1
2 EAST
RUL 2
Pressure
60
09:21
10:21
0.00
Pass
Yes
Tank # 3
Line # 1
TLD-1
3
PREMIUM
Pressure
60
09:20
10:20
0.00
Pass
Yes
Tank # 3
Line # 2
TLD-1
3
PREMIUM
Pressure
60
09:21
10:21
0.00
Pass
Yes
Tank # 4
Line # 1
TLD-1
4
Low Sulfur
Diesel
Pressure
60
09:20
10:20
0.00
Pass
Yes
Tank # 4
Line # 2
TLD-1
4
Low Sulfur
Diesel
Pressure
60
09:21
10:21
0.00
Pass
Yes
Technician Comments: UT151
Technician Name:David Mathie Certification #:41442 exp:
10/20/2025
Technician Signature:

Environmental Compliance for Petroleum Systems
©2025 Tanknology Inc., Austin, TX. All rights reserved. tanknology.com
Neighborhood Market #5109
4570 S 4000 W
West Valley City UT 84120
NM5109
Tanknology, Inc.
WALMART/SAM'S CLUB
DEPT. 9641 2101 SE Simple Savings Dr.
BENTONVILLE AR 72716
479-360-2779
05/29/2025
RUL RUL 2 Low Sulfur
DieselVeeder Root
FX1V
Veeder Root
FX1V
Veeder Root
FX1V
Veeder Root
FX1DV
40
2
40
2 2
38 38
2
UT151
David Mathie
NW1-2380030
PREMIUM
T1 WEST:1 T2 EAST:1 T3:1 T4:1
Impact Valve
Inspection
Impact Valve Operational
Inspection
Work Order:2380030 Date:5/29/2025
Site Name/ID:Neighborhood Market #5109
Address:4570 S 4000 W
City:West Valley City State:UT Zip:84120
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 40 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 85 Pass Fail Not Tested
9/10 91 Pass Fail Not Tested
11/12 40 Pass Fail Not Tested
11/12 85 Pass Fail Not Tested
11/12 91 Pass Fail Not Tested

Technician Comments:
Technician Name:David Mathie
Signature:
Environmental Compliance for Petroleum Systems
©2025 Tanknology Inc., Austin, TX. All rights reserved. tanknology.com
Neighborhood Market #5109 WALMART/SAM'S CLUB
4570 S 4000 W
West Valley City UT 84120
4002330
Tanknology, Inc.
DEPT. 9641 2101 SE Simple Savings Dr.
BENTONVILLE AR 72716
479-360-2779
800-964-1250 05/29/2025
1 2 3 4
RUL RUL2 PREM DSL
VR450PLUS VR450PLUS VR450PLUS VR450PLUS
19782 11904 7901 10420
118.4 118.4 118.4 118.4
UT151
David Mathie
4570 S 4000 W
Neighborhood Market #5109
4570 S 4000 W, West Valley City, UT 84120
NM5109
Tanknology, Inc.
WALMART/SAM'S CLUB
DEPT. 9641 2101 SE Simple Savings Dr.
BENTONVILLE, AR 72716
479-360-2779
05/29/2025
ANNULAR ANNULAR ANNULAR STP STP STP STP
RUL RUL/PREM DSL RUL RUL2 PREM DSL
UT151
David Mathie
4570 S 4000 W
Neighborhood Market #5109
4570 S 4000 W, West Valley City, UT 84120
NM5109
Tanknology, Inc.
WALMART/SAM'S CLUB
DEPT. 9641 2101 SE Simple Savings Dr.
BENTONVILLE, AR 72716
479-360-2779
05/29/2025
UDC UDC UDC UDC UDC UDC
1/2 3/4 5/6 7/8 9/10 11/12
UT151
David Mathie
Neighborhood Market #5109
4570 S 4000 W
West Valley City, UT 84120
4002330
Tanknology, Inc.
WALMART/SAM'S CLUB
479-360-2779
05/29/2025
DEPT. 9641 2101 SE Simple Savings Dr.
BENTONVILLE, AR 72716
1
RUL
5
OPW
2
RUL2
5
OPW
3
PREM
5
OPW
4
DSL
5
OPW
15 WC
947
15 WC
952
5 MIN
0
15 WC
954
15 WC
959
5 MIN
0
15 WC
1001
15 WC
1006
5 MIN
0
15 WC
1008
15 WC
1013
5 MIN
0
UT151
David Mathie
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 5/29/2025 Work Order 2380030
Cust Name / Location Number NM5109
Street Address 4570 S 4000 W
City, State, ZipCode West Valley City UT 84120

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 WEST
RUL
Dual Point
Straight w/ Flapper
5.50
Swivel
Swivel (poppet)
No

2 EAST
RUL 2
Dual Point
Straight w/ Flapper
5.75
Swivel
Swivel (poppet)
No

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

GAS
Pressure Vacuum cap
3
8

Describe Work Required

Surveyed by Signature
ANNUAL CONTAINMENT SUMP INSPECTION
This form may be utilized to document the inspection of containment sumps.
Date of Inspection
5/29/2025
UST Facility Person Conducting Test
Facility Name
Neighborhood Market #5109
Facility ID #
NM5109
Tester's Name
DMATHIE
Physical Address
4570 S 4000 W
Company
Tanknology Inc.
City
West Valley City
County
SALT LAKE
State
UT
Certification #
41442
Expiration Date
10/20/2025
UST Owner
WALMART/SAM'S CLUB
Tester's Signature Date
5/29/2025
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 2025
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 WEST RUL - 1
Y
Y
Y
Y
N
Pass
STP:2 EAST 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: 2380030
Site Diagram
(This site diagram is for reference only and is not drawn to scale)

Work Order:2380030
Site ID / Name:NM5109 / Neighborhood Market #5109
Address:4570 S 4000 W
City:West Valley City State:UT Zip:84120