HomeMy WebLinkAboutDERR-2025-004252UST Annual Compliance Inspection
Facility Information
Name:Fast Stop 1122 Certification/Inspection #:54138
Address:25 N BEAR LAKE BLVD, GARDEN CITY, UT, 84028 State ID:0100080
Phone Number:Form Completed By:Ray Simms Date:09/05/2024
Tank Information
State Tank ID T4 DSL T2 ETH
FREE
T3 PUL T1 RUL
Facility Tank # or ID (designation used by facility)T4 DSL T2 ETH
FREE
T3 PUL T1 RUL
Tank Capacity 4706 gal 4218 gal 6900 gal 9816 gal
Product Name (describe in comments if not listed)Diesel Ethanol Free
Unleaded
Premium Unleaded
Compartment Only (mark only if NOT the entire tank)
Manifolded Tank (mark for true siphon manifold ONLY)
Tank Status*
if Tank Status = TC:IU IU IU IU
Date in TC (assessment & OPS extension required > 1yr)
Emptied to 1" or less? (release detection required if not)Y N
NA
Y N
NA
Y N
NA
Y N
NA
Date emptied to 1" or less
Tank Release Detection Method*ATG-CSLD ATG-CSLD ATG-CSLD ATG-CSLD
Tank Corrosion protection*FRP-N/A FRP-N/A FRP-N/A FRP-N/A
Tank Wall Type*FRP FRP FRP FRP
Tank receives > 25 gallons at a time?Yes No Yes No Yes No Yes No
Spill Bucket? (required where UST receives >25 gallons at a time)Yes No Yes No Yes No Yes No
Spill Bucket Size
Spill Bucket Wall Type*
Overfill Protection? (required where UST receives >25 gallons at a time)Yes No Yes No Yes No Yes No
Overfill Protection Type*External
Overfill Alarm
External
Overfill Alarm
External
Overfill Alarm
External
Overfill Alarm
Piping Corrosion protection*Flex-N/A 0 0 Flex-N/A
Flexible Connection - Tank*
Flexible Connection - Dispenser*
Piping Wall Type*DW DW DW DW
Piping Delivery System*Pressure Pressure Pressure Pressure
Line Leak Detector Type (required for PR system)*Mechanical Mechanical Mechanical Mechanical
Piping Release Detection Method*Annual Line
Test
Annual Line
Test
Annual Line
Test
Annual Line
Test
STP (Turbine Pump) Containment Sump?No No No No
STP Containment Sump Wall Type*NA NA NA NA
UDC (Under-dispenser) Containment Sump?No No No No
UDC Containment Sump Wall Type*NA NA NA NA
Piping Transition Sumps?No No No No
Transition Sump Wall Type*NA NA NA NA
Comments
Inspection Checklist
For each facility, complete the Annual Compliance Inspection Checklist below by answering the questions. If the facility contains more
than 5 tanks or 8 dispensers, additional copies of this form must be completed. Questions are designated as either a mandatory
compliance item(●) or a recommended practice item(®). If an item is identified as mandatory and recommended, further information is
provided in a note following the question. If "No" is the answer for any mandatory compliance item(●) question, an associated entry must
be made in the Return to Compliance Plan with documentation of the date when the issue was brought back into compliance. The State
must approve all compliance plan schedules. If "No" is the answer for a recommended practice item (®), it is strongly suggested that the
deficiency be corrected.
Tank Information
Inspection Item T4 DSL T2 ETH
FREE
T3 PUL T1 RUL
Fill Equipment
●1 Is there a product tag on the fill riser pipe or are the lids painted in
accordance with a posted product code color chart?
Y Y Y Y
®2 Does the fill cap have adequate clearance between the cap and the
manhole cover?
Y Y Y Y
●3 Does the tank have a drop tube that extends to within 6 inches of the bottom
(if no diffuser is present)?
Y Y Y Y
Spill & Overfill Protection
●4 Is each UST that receives more that 25 gallons of product at any one time
equipped with spill and overfill prevention?
Y Y Y Y
●5 Is the spill bucket free of fuel, water or debris?Y Y Y Y
●6 Is the spill bucket in good condition and free of damage?Y Y Y Y
®7 Does the drain assembly work?Y Y Y Y
●8
Is the tank(s) equipped with an overfill device (e.g. overfill alarm, automatic
shut-off device or ball-float valve) and is the device installed according to
manufacturer's specifications to allow proper functionality?
Y Y Y Y
●9 Is the tank overfill alarm mounted near the fill port where it can be seen or
heard by the delivery person?
Y Y Y Y
Temporary Closure
●10
If the tank is in temporary closure and contains greater that 1 inch of
product, is approved release detection performed and maintained? NOTE:
OPS recommends that a tank in temporary closure be emptied (contains <=
1 inch of fluids).
NA NA NA NA
●11 If the tank is in temporary closure, is corrosion protection maintained?NA NA NA NA
●12
If the tank has been in temporary closure for greater than 3 months, is the
vent line open and has the piping, pumps, manways, and ancillary
equipment been capped and secured?
NA NA NA NA
Vapor Recovery (if Required)
●13 Are the vapor recovery adaptor and cap present and free of damage?NA NA NA NA
®14 Does the vapor cap have adequate clearance between the cap and the
manhole cover to enable hook-up?
NA NA NA NA
®15 Is the vapor cap in good condition with a gasket?NA NA NA NA
®16 Is the vapor recovery lid painted orange?NA NA NA NA
Submersible Turbine Pump (STP) Sump
®17 Are the external and/or internal lids easily removed for inspection?Y Y Y Y
®18 Are the sump lid, gasket and seals present and in good condition?Y Y Y Y
●19 Is the sump free of fuel, water or debris?Y Y Y Y
●20 Is the sump free of cracks, holes, bulges, or other defects?Y Y Y Y
●21
If the system contains secondarily contained piping with release detection
consisting of sump sensors installed in the sump, is the interstice open to
the sump?
Y Y Y Y
●22 Is the sump sensor properly mounted at the bottom of the sump and
operating according to the manufacturer's specifications?
Y NA Y NA
●23
Are penetration fittings and entry boots intact, secure and free of damage?
NOTE: If the sump was installed prior to 8-1-08 and is not used for
interstitial monitoring, this is a recommended item.
Y Y Y Y
®24 Are junction boxes sealed and free of corrosion?Y Y Y Y
●25 Are the STP components, piping and flex connectors free of leaks or seeps?Y Y Y Y
●26 If no sump is present, are metal components that are in contact with the soil
cathodically protected?
NA NA NA NA
●27 Are piping and flexible connectors installed according to the manufacturer's
specifications (not kinked or twisted)?
Y Y Y Y
●28
Did the mechanical and/or electronic line-leak detector pass its annual
functionality test which includes a leak simulated in the line as part of the
functionality test?
Y Y Y Y
®29 Is the mechanical leak detector properly vented? (vent tube not kinked or
twisted)
Y Y Y Y
ATG Port
®30 Is the manhole cover in good condition and is there adequate clearance
between the ATG probe cap and the manhole cover?
Y Y Y Y
®31 Is the cap in good condition and does it seal tightly?Y Y Y Y
®32 Are the probe wiring hole, electrical junction box and conduit sealed and in
good condition?
Y Y Y Y
●33 Are the probe, floats, and water/product warning alarms operating according
to the manufacturer's specifications?
Y Y Y Y
ATG Console
●34 Does the ATG console have power?Y Y Y Y
●35 Have all ATG leak alarms been properly addressed?Y Y Y Y
●36
Is the console programmed correctly for the tanks found at the site (e.g.
product, capacity, points, overfill alarm, in-tank test, line-leak detector test,
etc.)?
Y Y Y Y
●37 Is the sump sensor properly mounted at the bottom of the sump?Y NA Y NA
●38 Are the sensors functioning according to the manufacturer's specifications?Y Y Y Y
Tank Interstice
●39 Are the interstitial sensors placed correctly in the tanks?Y NA Y NA
●40 Are the interstitial sensors functioning according to the manufacturer's
specifications?
Y NA Y NA
Cathodic Protection
●41
Are all system components that routinely contain product (tanks, lines, and
other metal components) and that are in contact with the soil properly
cathodically protected?
NA NA NA NA
●42
Has your cathodic protection system (galvanic anodes or impressed current)
been tested within 6 months of installation/repair, and every 3 years
thereafter?
NA NA NA NA
●43 Has the impressed current system (rectifier) been inspected for proper
operation at least every 60 days?
NA NA NA NA
●44
If you have an internally-lined tank without additional cathodic protection,
has it passed and internal inspection within 10 years after installation of the
lining and every 5 years thereafter?
NA NA NA NA
®45 If the system is equipped with impressed current, there are no damaged,
frayed or exposed wires?
NA NA NA NA
Vent Piping
®46 Is the vent cap present and is it the correct type?Y Y Y Y
●47 Is the vent piping of correct height and above obstructions?Y Y Y Y
●48 Are diesel and gasoline tanks vented with separate piping?Y Y Y Y
Unattended Fueling
●49
Is one or more clearly identified emergency shutoff devices located not less
than 20 ft. or more than 100 ft. from the dispensing devices, readily
accessible to patrons?
Y Y Y Y
5
●50 Is a working telephone or other approved, clearly identified means to notify
the fire department provided on the site, and readily accessible to patrons?
Y Y Y Y
●51
Is a fire extinguisher with a minimum rating of 40-B, a maintenance
inspection not older than 1 year, and located no more than a 30 ft, travel
distance from the dispensing devices, readily accessible to patrons?
Y Y Y Y
Monthly Inspection
●52 Have all Monthly inspections been performed and documented, and have all
deficiencies noted during the inspections been corrected?
Y Y Y Y
Dispenser Information
Inspection item 1/2 3/4 5/6 7/8 9/10
●53 Is hanging hardware free of visible signs of leakage or damage?Y Y Y Y Y
●54 Are all components of hanging hardware of the proper type and size?Y Y Y Y Y
●55 If applicable, is fuel product, safety, octane, diesel sulfur, ethanol, signage present and correct?Y Y Y Y Y
●56 Is the under-dispenser containment(UDC) sump free of fuel, water or debris?NA NA NA NA Y
●57 Is the UDC sump free of cracks, holes, bulges, or other defects?NA NA NA NA NA
®58 Are penetration fillings and entry boots intact, secure and free of damage? NOTE: If the sump was
installed prior to 8-1-2008 and is not used for interstitial monitoring, this is a recommended item.
NA NA NA NA NA
●59 If the system contains secondarily contained piping with release detection consisting of sump sensors
installed in the sump, is the interstice open to the sump?
Y Y Y Y Y
●60 Is the sump sensor properly mounted at the bottom of the sump?NA NA NA NA Y
●61 Are junction boxes sealed and free of corrosion?Y Y Y Y Y
●62 Are meters, piping and flexible connectors free of leaks or seeps?Y Y Y Y Y
●63 Are piping and flexible connectors installed according to the manufacturer's specification? (not kinked or
twisted)
Y Y Y Y Y
●64 If no UDC, are any metal piping components in contact with the soil properly cathodically protected?Y Y Y Y NA
●65 Are the shear valves operating according to the manufacturer's specifications?Y Y Y Y Y
●66 Is at least one fire extinguisher with a minimum rating of 40-B, and a maintenance inspection not older
than 1 year, located within 100 feet of each dispenser and tank fill opening?
Y Y Y Y Y
●67 Is an emergency stop button present and operable?Y Y Y Y Y
Note:
Operator Certification
By signing below, the operator certifies that the answers above are accurate and based upon performance of associated inspection
activities, and that the facility owner has received a copy of this inspection form.
Contractor Printed Name:Ray Simms Contractor Company Name:CGRS, Inc.
Certification Number:21899
Contractor Signature:
A or B Operator Printed Name:A or B Operator Cert. No.:
A or B Operator Signature:Date:09/05/2024
Automatic Tank Gauge Inspection
ATG 1
ATG 1669
Facility Information
Name:Fast Stop 1122 Certification/Inspection #:54139
Address:25 N BEAR LAKE BLVD, GARDEN CITY, UT,
84028 State ID:0100080
Phone Number:Form Completed By:Ray Simms Date:09/05/2024
ATG Console Inspection
Tank Level Monitor Brand :Incon
1.Status upon Arrival:All Functions Normal
2.Status upon Departure:All Functions Normal
3.Is the display in good
condition and functioning?:
Yes
4.Is the keypad in good
condition?:
Yes
Tank Level Monitor Model :TS-550 Evo
5.Are all indicator lights
functional?:
Yes
6.Is printer functional?:Yes
7.Back-up battery tested? (if
applicable)?:
8.Back-up battery voltage (if
applicable):
Tank Information
Probe and Programing Inspection:
9.Tank # T3 PUL T1 RUL T4
DSL T2 ETH FREE
10.Tank Facility ID T3 PUL T1 RUL T4
DSL T2 ETH FREE
11.Tank # per ATG 3 1 4 2
12.Product:Premium Unleaded Diesel Ethanol Free
Unleaded
13.Tank Volume, gallons 6900 9816 4706 4218
14.Tank Dia/depth, inches 90.5 91 90.5 90.5
In-Tank Setup Parameters:
15.Thermal coefficient
16.ATG Programmed Diameter 90.5 91 90.5 90.5
17.Number of points on profile 11 10 10 10
Pass/Fail Criteria: if any of questions 19, 20 ,21 & 22 are No, then the system has failed the test.
Comment
Operator Certification
Contractor Signature:Printed Name:Ray Simms
18.Full volume on profile 6900 9816 4706 4218
19.After removing the probe from the tank, it has been inspected and any
damaged or missing parts replaced?
Yes Yes Yes Yes
20.Do floats move freely along the stem without binding?Yes Yes Yes Yes
21.Does product level match console value?Yes Yes Yes Yes
22.Does water level match console value?Yes Yes Yes Yes
23.Water warning (inches)(1")2 2 2 2
24.High water limit (inches)(1.5")2 2 2 2
25.Does console water alarm trigger at programmed level?Yes Yes Yes Yes
26.Programmed Overfill Limit (90%)90 90 90 90
27.Does console overfill alarm trigger at programmed level?Yes Yes Yes Yes
28.Programmed High Product Limit (95%)95 95 95 95
29.Does console high product alarm trigger at programmed level?Yes Yes Yes Yes
30.Low Product (15% of tank volume or 15" whichever is greater)500 925 300 925
31.Tank test program enabled?Yes Yes Yes Yes
32.Tank Test Method?CSLD CSLD CSLD CSLD
33.Tank Test Rate 0.2 0.2 0.2 0.2
34.Test duration (hrs)CONT CONT CONT CONT
35.12 months of tank test history present?Yes Yes Yes Yes
Lines:
36.Electronic Line Leak Type NA NA NA NA
37.Line # and label in ATG (Q1, Unleaded)N/A N/A N/A N/A
38.Line Test Rate N/A N/A N/A N/A
39.12 months of line test history present?NA NA NA NA
40.Test Result Pass Pass Pass Pass
Line Test
Facility Information
Name:Fast Stop 1122 Certification/Inspection #:54140
Address:25 N BEAR LAKE BLVD State ID:0100080
Phone Number:Form Completed By:Ray Simms Date:09/05/2024
Tank Test Information
Tank #:T1 RUL T2 ETH FREE T3 PUL T4 DSL
Capacity:9816 4218 6900 4706
Product:Unleaded Ethanol Free
Unleaded
Premium Diesel
Line Test Information
Line #:RUL ETH FREE PUL DSL
LineType:Pressure Pressure Pressure Pressure
Line Material:DW Flex DW Flex DW Flex DW Flex
Line ID Size (in):2 2 2 2
Line Length (ft):150 150 150 150
Pump Type:FE Petro FE Petro FE Petro FE Petro
Associated Tank:T1 RUL T2 ETH FREE T3 PUL T4 DSL
Test Equip. Mfg.:Triangle Triangle Triangle Triangle
Test Pressure (PSI):50 50 50 50
Initial Cyl. Level:350 410 420 400
Final Cyl. Level:350 400 420 400
Change in Time (mins):15 15 15 15
Change in Vol:0.0000 -10.0000 0.0000 0.0000
Change in Temp (F):0 0 0 0
Coeff. Of Thermal Expansion (g/F):0.00070 0.00070 0.00045
Line Vol (gal):24.47 24.47 24.47 24.47
Leak Rate (GPH):0.0000 -0.0106 0.0000 0.0000
Result:Pass Pass Pass Pass
Notes
TIGHTNESS TESTING CERTIFICATION
CGRS certifies that the systems in the above table have been tested utilizing leak detection methods which meet the prescribed leak rate testing
standard of 0.10 gph with a minimum probability of detection of 95% and a 5% probability of a false alarm. CGRS further certifies that the protocol for
each test method was strictly adhered to, and that all precision tightness testing performed by CGRS was conducted in accordance with EPA 40 CFR
parts 280.43(c) and 280.44(b) and the National Fire Protection Association, Bulletin NFPA 329 criteria.
Contractor Printed Name:Ray Simms Contractor Signature:
Certification Number:1651,UT 407
If any answers in Questions 3,4,5,6,7,11,13 or 14 are No, the system has failed the test.
Overfill Alarm Inspection
Facility Information
Name:Fast Stop 1122 Certification/Inspection #:54141
Address:25 N BEAR LAKE BLVD, GARDEN CITY, UT, 84028 State ID:0100080
Phone Number:Form Completed By:Ray Simms Date:09/05/2024
Overfill Alarm Information
This procedure is to determine wheather 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 inspection procedure. This procedure is applicable to tank level monitor stems that touch the bottom of the tank when in place.
Tank #T1 RUL T2 ETH FREE T3 PUL T4 DSL
Tank Facility ID T1 RUL T2 ETH FREE T3 PUL T4 DSL
Product Stored Unleaded Ethanol Free
Unleaded
Premium Diesel
Tank Level Brand Incon Incon Incon Incon
Tank Level Model TS-550 Evo TS-550 Evo TS-550 Evo TS-550 Evo
1. Tank Diameter, in 91.000 90.500 90.500 90.500
2. Actual Tank Capacity, gal 9816 4208 4706 6900
3.Overfill alarm activates in the test mode at
the console?
Y Y Y Y
4.When activated, overfill alarm can be heard
or seen while delivering to the tank?
Y Y Y Y
5.After removing the probe, it has been inspected
and any damage or missing parts replaced?
Y Y Y Y
6. Float moves freely on stem without binding?Y Y Y Y
7. Moving product level float up stem triggers alarm?Y Y Y Y
8.Inch level from bottom of stem when 90% alarm is
triggered
81 81 81 81
9. Calculated tank volume from Question 8 8496 3755 4058 6047
10. Tank % full 86.55 89.23 86.23 87.64
11. Is Question 10 less than 90%Y Y Y Y
12.Fuel float level on the console agrees with the
gauge stick reading?
Y Y Y Y
13. Overfill activates at 90% or less of tank capacity?Y Y Y Y
14.Fuel float level on the console agrees with the
gauge stick reading
Y Y Y Y
Test Results Pass Pass Pass Pass
Comments
Operator Certification
Contractor Printed Name:Ray Simms Contractor Signature:
Fcility Name
Address5 N Por Like B acdylll
1
NAME(S) AND INITIALS OF PERsON(S) CONDUCTING MONTHLÝ INSPECTIONS;
5
6
2 Records of release detection (tanks and piping) are reviewed and current.
Please respond to ALL of the following questions with a Y (Yes), N (No). or NA (Not Applicable) answer.
Months of the Current Year J F MA M J
Monthly Inspection Release Detection
3 Equipment is undamaged, intact and free from defects.
10
UST Operator Inspection -Utah
YEAR_24
Release detection equipment is operating with no alarms or other unusual
operating conditions.
Monthly Inspection -Spill Prevention Equipment
Equipment is free from debris, water, or product.
Fill Pipe is unobstructed.
Fill cap is un-broken and is securely on the fill pipe.
Secondary Containment Sumps
(STP, Dispenser and Transition)
9 Double Walled Sumps
7 Double walled spill prevention equipment -Interstitial area is free from leaks./VV/
equipment
Primary Class B Operator n Hst
Annual Inspection -Containment Sumps
Hand-held release detection
Initials of person performing Inspection.
Facility ID
Comments/Follow up:
Date of annual lnspection
and that it is true, accurate and was completed in accordance with R311-203-7.
Visual Inspection of sump indicates no damage and it is free from debris, water and fuel.
The penetration fittings for conduits and piping entering the STP Sumps are intact.
|Interstitial area is free from leaks.
Hand-held release detection eguipment (bailer, gauge stick, etc.) is serviceable and
operable.
I certify under penalty of law that I am the Class B Operator referenced above and that I am familiar with information on this form
ASo N D
Signature of the Primary Class B Operator (Sign this document after the last inspection of the Current Year) Date
B Operator #
Turn over for record of Interstitial MMonitoring Vsuat nspections and Impressed Current rectifier checks.
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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 _______________________________________________
Fast Stop 1122
25 N. Bear Lake 25 N. Bear Lake
Garden City, UT Garden City, UT
0100080
CGRS 9-5-24
PUL STP DSL STP D9/10 DSL INT
PUL DSL DSL ETH FRE DSL PUL
Ray Simms
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 __________________________________
Fast Stop 1122
25 N. Bear Lake 25 N. Bear Lake
Garden City, UT Garden City, UT
0100080
CGRS 9-5-24
1 2 3 4
RUL ETH FREE PUL DSL
VMI RED JACKET FE PETRO VMI
LD2000 FX1V MLD LD2000
26 29 27 32
24 25 25 30
150 100 100 120
1 1 1 1
9 10 9 13
2 3 3 4
Ray Simms
UTAH SPILL PREVENTION TEST
Spill Bucket Hydrostatic Test Form
Tester’s Signature______________________________
Facility Name Facility ID
Address Tester’s Name
Test Date Phone
Tank number
Product Stored
Capacity
Manufacturer
Construction Single walled
Double walled Single walled
Double walled Single walled
Double walled Single walled
Double walled Single walled
Double walled Single walled
Double walled
Liquid and debris
removed
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Visual Inspection
No cracks, holes
or separations.
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Tank riser cap
included in test?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Is drain valve
included in test?
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Start Level
Start Time
Ending Level
End Time
Test Period
(Minimum of 1 hour)
Change in Level
Test Results Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Photos indicating water
levels are attached?
Pass/fail criteria: Must pass visual inspection, test duration at least one hour, must include photos with this form, water level
drop of less than 1/8 inch. Ref: PEI/RP 1200 6.2.5 Test Procedure
How was the liquid disposed?
Comments
I certify under penalty of law that the above information is true, accurate and complete. Aug 2016
Fast Stop 1122 0100080
Ray Simms - CGRS
25 N. Bear Lake, Garden City, UT 9-5-24
1
RUL
5
OPW
NA NA
11 11.5 -15 -15
1200 1200 1215 1220
11 11.5 -14.68 -14.97
1300 1300 1216 1221
1 HOUR 1 HOUR 1 MIN 1 MIN
0.32 0.03
2 3 4
ETH FREE PUL DSL
5 5 5
OPW EBW EBW