DERR-2025-002065

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CANARY ,.,... Servlcer7Requnter ·
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PINK .:. ServieerlFinance . •
GOLOENROO -~lj;er ••
INTER-D,EPARTMENTAL TRANSFER DIV ISIO N OF FINANC E NO .•
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ic wZJ ,,
Oate-,......--;t-t-"'""""' N_ov •. 11, 1989
SERVICER ORG . :Ytaa DcJ;l a :rtme~t ef Health
... . ...
REQUESTER ORG . Bept::. of 'fiamspotta tiou D*st.' ·one
SER VIC ES PRO VIDED : :
''
ORG. " ACCT .
ORG. ACCT .
Unde rgrou nd storage tanks
i nvo ice! 1 1184 8 12 1 6261
11 175 8 1'22 6261
11 158 8 123,. 6 26,1
11185 . 8 124 6 26 1
111 76 8 125 6261
111 77 . 8 12 6 62 61
111 5 9 8 131 '62 6 1 ·
11 160 '8 131A • 6 26 1 .
1 114 2 8 13 3 . 6 2 6 i
1.1 16 1 0 /lJ,/;:,).;),~ 8 13 5 626 1
1 116 2' · 8 13 6 ,62 61
1116 3 8136A · 626 1
11164 8 137 6 261
11 165 8 13 7A 6~61 '
11178 88 11 6261
111 66 8 14 5 6 26 1
11168 8 148 • 6 2 61 •
DE SCRIPTI ON
25 Charact ers , I I
857333
. _SERV I C ER-OEPA RTME~TA L NO:.
C OMPUT:A T IO NS C HECK ED BY
PRE-AU DITED BY
SER VICER (CREQI.T ) •
TASK OPT.· ·ACTIVITY AMOUNT · UNITS
REQU EST ER (DEBIT)
TASK OPT. . ACTIVITY AMOUNT UNITS
STD \\O\o\
STD 11010 1
STD 110101
STD 110101
STD . 110101
STD 110101 ·
STD 110101
STD 110101 · •
STD 110101
STD q.0101
STD · 110101
STD 11 0 10 1
STD .. 11 01 0 1
STD 11 0 101
S1I 045100
STD .110101
STD 110101 .•
.T OTAL ·-
. I I I I I I I I I
(Request or Department No. i f needed)
: ·.
NOTE: The original must be si gned by the re(luester agency and returneClto the serv icer department before the 25th of the month bi lleCI. The fu nds wi ll be transferred
automatically. on. the 25th of the month. If you have any questions about your billing . contact the. serv,icer department immediat ely.
Recei pt of the above items or services
acknowledged and transfer of funds authorized.
SERVICER DEPARTMENT HEAD OR AUTHORIZED AGENT .......REOUSTER D~PARTtlENT H.EAD O R AUTHORI ZED AGENT
APPLIED ENVIRONMENTAL SERVICES, L.C.
PO BOX 182 ROY, UTAH 84067 [phone]
TEI 5000 NON VOLUMETRIC, TEI 4000 VOLUMETRIC, TEI ULLAGE, TEI L T3
These systems meet all requirements set forth by USEPA 40 CFR and has received third party certification.
PRECISION TANK & LINE TEST RESULTS SUMMARY
INVOICE ADDRESS: TANK LOCATION:
STATE FUEL NETWORK UTAH DOT# 134
PO BOX 141152 1150 SOUTH CENTER
SALT LAKE CITY, UTAH 84141-1152 WELLSVILLE, UTAH
DATE:
6-9-2008
TIME START:
11 :30
TIME END:
13:30
WORK ORDER # 08166
DEQ ID# 100222
TECHNICIAN: SM
TECH# 94027
STATE TECH# UT 0121
GROUNDWATER DEPTH:
N/A OW TKS
TANK TANK PRODUCT TANK VENT PRODUCT LINE LEAK WATER IN PUMP TANK
MATERIAL
1.
2.
3.
4.
5.
6.
CAPACITY
4000
6000
M/UL
DSL
PASS
PASS
PASS
PASS
LINE DETECTOR TANK TYPE
PASS
PASS
PASS
PASS
1.0"
0.0"
PRESS
PRESS
DWF
DWF
PRODUCT LINES TESTED AT50 PSI FOR 15 MIN
LINE RATES (GPH)
LINE LEAK DETECTOR TYPE & SIMULATED LEAK RATE
M = MECHANICAL E = ELECTRONIC # = (GPH) RATE
1. M/UL -.000
2. OSL -.000
3.
4.
5.
6. ~~ :: §§ 1.
2.
3.
TEST METHODS USED FOR THIS LOCATION
TEI 5000 NON VOLUMETRIC TANK TES10 TEI 4000 VOLUMETRIC TANK TESU TEI TANK ULLAGE TEST □ TEI L T3 LINE TEST 0
ADDITIONAL INFORMATION:
;,11 tests were performed according to manufacturer protocol, and within the common practices of the industry. However due to the variables of
tightness testing, these results cannot be guaranteed. There are no warranties expressed, written or implied.
CERTIFIED TECHNICIAN SIGNATURE: Digitally signed by STEVEN B MARTIN
cn=STEVEN B MARTIN, o=AES, c=US
Date: 2008.06.11 00:33:24-05'00'
Reason: I am the author of this document
DATE: 6-9-2008
Owner Name STATE FUEL NETWORK
Address 4120 STATE OFFICE BUILDING
Cit SALT LAKE CITY StateUT Zi 84114
Contact STEVE
Com for,
CANNING Phone [phone]
th&
Number of tanks at the facilit 3 4 4
8/10/1993 8/10/1993
6000 4000
artmented
Substance Stored
Tank is in use. No
Material of construction of tanks
Material of construction of i in
No
Location Name UDOT STA. #135 WELLSVILLE
Address 1150 S CENTER ST
Cit WELLSVILLE
Contact BOB SEELE
ffll'lif,&mallon for
Yes No Yes No
Yes No Yes No
Yes No Yes No
State UT Zi 84339
Yes
Yes
Yes
Phone [phone]
,,i~.
No Yes No
No Yes No
No Yes No
Overfill alarm audible or visible is driver can hear or see it, and is clearl identified.
Containment sum s are sealed, free from water, reduct, etc.
The results of the last two cathodic rotection tests are available within six months of installation and ever three ears thereafter .
Cathodic Protection Testin . Date of last test:
Impressed Current System is checked for proper operation at least every
60 da s and the results of the last three checks are available.
Tester
Yes No
UT
Dates of last three checks:
Indicate below the corrosion protection method in place for each UST system component. Identify each dispenser by pump number(s). Show readings
for the most recent cathodic rotection test.
Corr. Protect.
Method
2
Tanks
3
4
5
6
2
Lines
3
4
5
6
2
Tank 3
Flex 4
5
6
Disp.
Flex
Sacrificial
Anode
Im ressed Current
Instant Off De olarized
Site Drawing North
RECEIVFD
MAR 2 4 2008
i..Jt:U
Environmentai Response & Remediation
11111111111111111 ■1 ■111 lllllll II
DERR-2008-001125
Document Date· 03/?4/?008
Tl 02--3'
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TANK LEAK DETECTION ATG
Tank method used: .P<i' ATG Shutdown Testina r l ATG Continuous Testina r l Interstitial Monitorina
Manufacturer, name and model of system: Petro Vend Site Sentinel II
Circle Yes or'No1!ftf'~i&r'·"' mW •• • &)mfain"fi:lidentifv W'fiilf :mv e to.the an-····-·-'-·--in the.._. ""'1·-ft
IM Type of Secondary Containment used: I Type of IM Documentation used:
Records on site document that the system is properly installed, calibrated,
operated, and maintained (system and tank setup reports, maintenance @ No records). Written documentation of calibration, maintenance, and repair is
ATG IM keot for at least one year after work is comoleted.
ATG console or other equipment used to take readings and perform tests is I@ No ATG IM adeauate, accessible, and ooerational.
Documentation of valid testing or monitoring is available for the last 12 ~ No ATG IM months. Show results in table below.
The probe is located at the
(Y-9 No If not in center, show tilt factors Tilt: #1 #2 #3 #4 #5 #6
ATG center of the tank. from the setup report.
The tank was filled to at least the minimum level required to ensure a valid @ No Third Party Minimum Level: S cf /b ATG leak test, and the tank size is within the allowed upper and lower size limits.
IM System is capable of detecting a release of regulated substances from any Yes No portion of the primary tank/ i in within one month of release
• Shewresultsof ~foread!'.'.. tilahest J)l'OdUCt ..-Mled fol' ·' ~:?:•: the
Mo/Yr 11 o?, 21(:fb 3lc)'g 4107 5fo'] 61()7 71 07 BIIJ7 9167 1010 7 11ltJ7 12/07
# I ~ ? u,Rn..t~ /) p I' p p ,p f-' f> .p
# I-"' ~ ,,./(.-,,,1>1''-.. '.fl /) ;p -p p .p -/J p ;p
# ' .
#
#
#
PIPING LEAK DETECTION ALD LTT
□ Piping qualifies as Safe Suction. Documentation is available and verifiable to show that piping operates at less than atmospheric pressure,
has only one check valve (under pump), and has proper slope of piping. If all these criteria are met, no leak detection is required on the piping.
Piping method(s) used. Pressurized piping must have an Automatic Line Leak Detector and one other form of leak detection.
~~tomatic Line Leak Detector. Tank 1 Tank2 Tank3 Tank 4 Tank 5 Tank 6
'
(B}E @ E Type(Mechanical, Electronic, Other): 0 0 M E 0 M E 0 M E 0 M E 0
Manufacturer and model of each leak detector:
Date of last leak detector {,p-1:1~a1 j,/455 f/,r55 performance test: Results:
Indicate type of test: Simulated Leak, 3 gph, .2 gph, .1 gph SL 3 .2 .1 SL 3 .2 .1 SL 3 .2 .1 SL 3 .2 .1 SL 3 .2 .1 SL 3 .2 .1
(3, .2, .1-electronic LLD only)
/ Tester name: Cert. Number UT Test Method:
I
~'.Line tightness testing. /
ate of last line tightness test: {p-J ~-6 Results: t)15J ~
□ Same as above: Tester name: '7LU1 Cert. Number UT t).LZl Test Method: '1£ / / ""; '3
□ Monthly monitoring. □ .2 GPH Monthly Testing □ Interstitial Monitoring. Type of IM Documentation:
Indicate the method used: □ SIR □ GW Monitoring □ Vapor Monitoring
Show results of monthlv monitorina for DiDina for the last 12 months. Indicate Pass Fail Invalid or No Results for each month.
Mo/Yr 1/ 2/ 3/ 4/ 5/ 6/ 7/ 8/ 9/ 10/ 11/ 12/
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COMMENTS
Ldatgim0307.doc