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DERR-2024-006022
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: (512) 451-6334 Fax: (512) 459-1459 Date Printed and Mailed: 4/11/2024 UTAH DEPARTMENT OF ENV. QUALITY UST PO Box 144840 SALT LAKE CITY, UT 84114 Test Date: 4/4/2024 Order Number: 2365941 Dear Regulator, Enclosed are the results of recent testing performed at the following facility: SAMS CLUB 4730 (SC4730) 7571 SOUTH 3800 WEST WEST JORDAN, UT 84084 Testing performed: Sincerely, Dawn Kohlmeyer Manager, Field Reporting Product Line Tightness Test Page 1 of 1 Work Order: 2365941 Date: 4/4/2024 Site Name/ID: SAMS CLUB 4730 / SC4730 Address: 7571 SOUTH 3800 WEST City: WEST JORDAN State: UT Zip: 84084 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 T1-REG UNLEADED Pressure 60 06:08 07:08 0.00 Pass Yes Tank # 2 Line # 1 TLD-1 T2-REG UNLEADED Pressure 60 06:08 07:08 0.00 Pass Yes Tank # 3 Line # 1 TLD-1 T3-PREM PREMIUM Pressure 60 06:08 07:08 0.00 Pass Yes Tank # Line # Tank # Line # Tank # Line # 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 SAMS CLUB 4730 7571 SOUTH 3800 WEST WEST JORDAN UT 84084 SC4730 Tanknology, Inc. WALMART/SAM'S CLUB DEPT. 9641 2101 SE Simple Savings Dr. BENTONVILLE AR 72716 479-360-2779 04/04/2024 UNLEADED UNLEADED Red Jacket FX1V Red Jacket FX1V Red Jacket FX1VFX1VFX1VFX1V 30 20 225 2 10 3 30 20 250 2 10 3 30 20 500 4 10 5 UT151 David Mathie NW1-2365941 PREMIUM TT1-REG:1 TT2-REG:1 TT3-PREM:1 Impact Valve Inspection Impact Valve Operational Inspection Work Order:2365941 Date:4/4/2024 Site Name/ID:SAMS CLUB 4730 Address:7571 SOUTH 3800 WEST City:WEST JORDAN State:UT Zip:84084 How Inspected: Line Test NFPA 30A PEI RP1200 Other Dispenser Number Grade Secure Mount? Valve Lock?Pass/ Fail Comments 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 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 85 Pass Fail Not Tested 11/12 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 SAMS CLUB 4730 WALMART/SAM'S CLUB 7571 SOUTH 3800 WEST WEST JORDAN UT 84084 SC4730 Tanknology, Inc. DEPT. 9641 2101 SE Simple Savings Dr. BENTONVILLE AR 72716 479-360-2779 800-964-1250 04/04/2024 1 2 3 RUL RUL PREM VR450PLUS VR450PLUS VR450PLUS 19703 19703 19703 117.8 117.8 117.8 UT151 David Mathie 7571 SOUTH 3800 WEST SAMS CLUB 4730 7571 SOUTH 3800 WEST , WEST JORDAN, UT 84084 SC4730 Tanknology, Inc. WALMART/SAM'S CLUB DEPT. 9641 2101 SE Simple Savings Dr. BENTONVILLE, AR 72716 479-360-2779 04/04/2024 ANNULAR ANNULAR ANNULAR STP STP STP RUL RUL REM RUL RUL PREM UT151 David Mathie SAMS CLUB 4730 7571 SOUTH 3800 WEST WEST JORDAN , UT 84084 SC4730 Tanknology, Inc. WALMART/SAM'S CLUB 479-360-2779 04/04/2024 DEPT. 9641 2101 SE Simple Savings Dr. BENTONVILLE, AR 72716 1 RUL OPW 5 2 RUL OPW 5 3 PREM OPW 5 15WC 641 15WC 646 5 MIN 0 15 WC 648 14 WC 653 5 MIN 1 15WC 655 15 WC 700 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 4/4/2024 Work Order 2365941 Cust Name / Location Number SC4730 Street Address 7571 SOUTH 3800 WEST City, State, ZipCode WEST JORDAN UT 84084 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 T1-REG UNLEADED Dual Point Straight w/ Flapper 5.50 Swivel Swivel (poppet) No ONLY VENT Pressure Vacuum cap 3 8 T2-REG UNLEADED Dual Point Straight w/ Flapper 5.50 Swivel Swivel (poppet) No T3-PREM PREMIUM Dual Point Straight w/ Flapper 10.00 Swivel Swivel (poppet) No 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 4/4/2024 UST Facility Person Conducting Test Facility Name SAMS CLUB 4730 Facility ID # 4730 Tester's Name DMATHIE Physical Address 7571 SOUTH 3800 WEST Company Tanknology Inc. City WEST JORDAN County SALT LAKE State UT Certification # 41442 Expiration Date 10/20/2025 UST Owner WALMART/SAM'S CLUB Tester's Signature Date 4/4/2024 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:T1-REG UNLEADED - 1 Y Y Y Y N Pass STP:T2-REG UNLEADED - 1 Y Y Y Y N Pass STP:T3-PREM PREMIUM - 1 Y Y Y Y N Pass Comments: WO: 2365941 Site Diagram (This site diagram is for reference only and is not drawn to scale) Work Order:2365941 Site ID / Name:SC4730 / SAMS CLUB 4730 Address:7571 SOUTH 3800 WEST City:WEST JORDAN State:UT Zip:84084 W.O.# NW1-2365941 +AAE- I10100 04/04/24 7:39 AM 227110 Sams's Club 4730 7571 South 3800 West West Jordan UT 84084 SYSTEM STATUS REPORT ID CATEGORY DESCRIPTION ALARM TYPE STATE DATE TIME ALL FUNCTIONS NORMAL +AAMAAQ- I90200 04/04/24 7:40 AM SOFTWARE REVISION LEVEL VERSION 33.48 SOFTWARE+ACM- 342005-010-B- CREATED - 21.10.28.21.27 +AAMAAQ- I20100 04/04/24 7:40 AM 227110 Sams's Club 4730 7571 South 3800 West West Jordan UT 84084 IN-TANK INVENTORY TANK PRODUCT VOLUME TC-VOLUME ULLAGE HEIGHT WATER TEMP 1 T1-Unleaded 13579 0 6124 75.76 0.00 59.80 2 T2-Unleaded 13575 0 6128 75.74 0.00 59.36 3 T3-Premium 6684 0 13019 43.75 0.00 54.43 +AAMAAQ- I30100 04/04/24 7:40 AM 227110 Sams's Club 4730 7571 South 3800 West West Jordan UT 84084 LIQUID STATUS REPORT SENSOR LOCATION STATUS 1 Unld. T1 STP Sump Normal 2 Unld. T2 STP Sump Normal 3 Prem. T3 STP Sump Normal 4 Unld Tank1 Int Space Normal 5 Unld Tank2 Int Space Normal 6 Prem Tank3 Int Space Normal +AAMAAQ- I30200 04/04/24 7:40 AM 227110 Sams's Club 4730 7571 South 3800 West West Jordan UT 84084 LIQUID ALARM HISTORY REPORT SENSOR LOCATION 1 Unld. T1 STP Sump 04/04/24 6:04 AM FUEL ALARM 04/10/23 6:30 AM FUEL ALARM 04/12/22 6:39 AM FUEL ALARM 04/20/21 6:07 AM FUEL ALARM 2 Unld. T2 STP Sump 04/04/24 6:05 AM FUEL ALARM 02/28/24 6:56 PM FUEL ALARM 04/10/23 6:31 AM FUEL ALARM 04/12/22 6:40 AM FUEL ALARM 04/20/21 6:07 AM FUEL ALARM 3 Prem. T3 STP Sump 04/04/24 6:06 AM FUEL ALARM 02/29/24 3:33 AM FUEL ALARM 04/10/23 6:33 AM FUEL ALARM 04/12/22 6:42 AM FUEL ALARM 04/20/21 6:08 AM FUEL ALARM 4 Unld Tank1 Int Space 04/04/24 6:20 AM FUEL ALARM 04/10/23 6:44 AM FUEL ALARM 04/12/22 6:59 AM FUEL ALARM 04/20/21 6:18 AM FUEL ALARM 5 Unld Tank2 Int Space 04/04/24 6:26 AM FUEL ALARM 04/10/23 6:48 AM FUEL ALARM 04/12/22 7:06 AM FUEL ALARM 04/20/21 6:20 AM FUEL ALARM 6 Prem Tank3 Int Space 04/04/24 6:27 AM FUEL ALARM 04/10/23 6:49 AM FUEL ALARM 04/12/22 7:09 AM FUEL ALARM 04/20/21 6:21 AM FUEL ALARM +AAMAAQ- I6SU00 04/04/24 7:40 AM -------------------------------------------------------- +ACoAKgAq- SETUP FOR ALL TANKS +ACoAKgAq- -------------------------------------------------------- ULLAGE DISPLAY MODE: FULL ULLAGE USER ULLAGE FULL ULLAGE LABEL: 100+ACU- ULLAGE USER ULLAGE: 90+ACU- PRINT TC VOLUMES: DISABLED TC REFERENCE TEMPERATURE: 60 DEG F PERIODIC TEST NEEDED WARNINGS: DISABLED DAYS BEFORE PERIODIC WARNING: 25 DAYS BEFORE PERIODIC ALARM: 30 ANNUAL TEST NEEDED WARNINGS: DISABLED DAYS BEFORE ANNUAL WARNING: 355 DAYS BEFORE ANNUAL ALARM: 365 TC DENSITY: DISABLED STICK HEIGHT: DISABLED LEAK TEST REPORT FORMAT: STANDARD LEAK TEST REGION: EPA -------------------------------------------------------- +ACoAKgAq- TANK SETUP +ACoAKgAq- -------------------------------------------------------- --- GENERAL SETUP - TANK 1 --- CONFIGURED: ENABLED LABEL: T1-Unleaded PRODUCT CODE: 1 PROBE NUMBER: Pb 1: Unld. Tk +ACM-1 Probe PROBE OFFSET: 0.00 INCHES FULL VOLUME: 19703 GALLONS DIAMETER: 117.8 INCHES TILT: 0.00 INCHES THERMAL COEFFICIENT: 0.000700 METER DATA PRESENT: ENABLED DELIVERY DELAY: 5 MINUTES GROSS TEST FAIL: ALARMS DISABLED PERIODIC TEST FAIL: ALARMS DISABLED ANNUAL TEST FAIL: ALARMS DISABLED GOST VOLUME CORRECTION: DISABLED --- LIMITS - TANK 1 --- MAX VOLUME: 19703 GALLONS HIGH PRODUCT: 95+ACU- DELIVERY OVERFILL: 90+ACU- DELIVERY LIMIT: 0+ACU- LOW PRODUCT: 600 GALLONS HIGH WATER WARNING: 1.00 INCHES HIGH WATER ALARM: 3.00 INCHES WATER ALARM FILTER LEVEL: LOW LEAK ALARM LIMIT: 15 GALLONS SUDDEN LOSS LIMIT: 50 GALLONS FUEL LOW TEMP LIMIT: -58.000 DEG F FUEL HIGH TEMP LIMIT: 140.000 DEG F --- ENVIRONMENTAL TESTS - TANK 1 --- TANK TEST METHOD: DISABLED --- PROFILE - TANK 1 --- TANK PROFILE: FOUR POINT +ACM- HEIGHT VOLUME +ACM- HEIGHT VOLUME --- ------ ------ --- ------ ------ 001 117.8 19703 003 58.9 9961 002 88.3 16051 004 29.4 3836 --- TANK 1 - CHART 1 --- LABEL: +ACoAKgAqACoAKg- TYPE: FOUR POINT SOURCE: USER ENTERED LAST CHANGE: 2022-08-20 STATUS: ACTIVE VOLUME ENTRY: TOTAL VOLUME +ACM- HEIGHT VOLUME +ACM- HEIGHT VOLUME --- ------ ------ --- ------ ------ 001 117.8 19703 003 58.9 9961 002 88.3 16051 004 29.4 3836 --- TANK 1 --- T1 SIPHON MANIFOLDED TO TANKS: 2 T1 LINE MANIFOLDED TO TANKS: NONE --- ACCUCHART - TANK 1 --- UPDATE SCHEDULE: NEVER CALIBRATION PERIOD: 120 DAYS WARNINGS: DISABLED MIN OPERATING LEVEL: 20+ACU- MAX OPERATING LEVEL: 70+ACU- --- HRM - TANK 1 --- WARNING LIMIT: 1 GALLONS ALARM LIMIT: 1 GALLONS MAXIMUM VOLUME LIMIT: 132 GALLONS --- GENERAL SETUP - TANK 2 --- CONFIGURED: ENABLED LABEL: T2-Unleaded PRODUCT CODE: 2 PROBE NUMBER: Pb 2: Unld. Tk +ACM-2 Probe PROBE OFFSET: 0.00 INCHES FULL VOLUME: 19703 GALLONS DIAMETER: 117.8 INCHES TILT: 0.00 INCHES THERMAL COEFFICIENT: 0.000700 METER DATA PRESENT: ENABLED DELIVERY DELAY: 5 MINUTES GROSS TEST FAIL: ALARMS DISABLED PERIODIC TEST FAIL: ALARMS DISABLED ANNUAL TEST FAIL: ALARMS DISABLED GOST VOLUME CORRECTION: DISABLED --- LIMITS - TANK 2 --- MAX VOLUME: 19703 GALLONS HIGH PRODUCT: 95+ACU- DELIVERY OVERFILL: 90+ACU- DELIVERY LIMIT: 0+ACU- LOW PRODUCT: 600 GALLONS HIGH WATER WARNING: 1.00 INCHES HIGH WATER ALARM: 3.00 INCHES WATER ALARM FILTER LEVEL: LOW LEAK ALARM LIMIT: 15 GALLONS SUDDEN LOSS LIMIT: 50 GALLONS FUEL LOW TEMP LIMIT: -58.000 DEG F FUEL HIGH TEMP LIMIT: 140.000 DEG F --- ENVIRONMENTAL TESTS - TANK 2 --- TANK TEST METHOD: DISABLED --- PROFILE - TANK 2 --- TANK PROFILE: FOUR POINT +ACM- HEIGHT VOLUME +ACM- HEIGHT VOLUME --- ------ ------ --- ------ ------ 001 117.8 19703 003 58.9 9961 002 88.3 16051 004 29.4 3836 --- TANK 2 - CHART 1 --- LABEL: +ACoAKgAqACoAKg- TYPE: FOUR POINT SOURCE: USER ENTERED LAST CHANGE: 2022-08-20 STATUS: ACTIVE VOLUME ENTRY: TOTAL VOLUME +ACM- HEIGHT VOLUME +ACM- HEIGHT VOLUME --- ------ ------ --- ------ ------ 001 117.8 19703 003 58.9 9961 002 88.3 16051 004 29.4 3836 --- TANK 2 --- T2 SIPHON MANIFOLDED TO TANKS: 1 T2 LINE MANIFOLDED TO TANKS: NONE --- ACCUCHART - TANK 2 --- UPDATE SCHEDULE: NEVER CALIBRATION PERIOD: 120 DAYS WARNINGS: DISABLED MIN OPERATING LEVEL: 20+ACU- MAX OPERATING LEVEL: 70+ACU- --- HRM - TANK 2 --- WARNING LIMIT: 1 GALLONS ALARM LIMIT: 1 GALLONS MAXIMUM VOLUME LIMIT: 132 GALLONS --- GENERAL SETUP - TANK 3 --- CONFIGURED: ENABLED LABEL: T3-Premium PRODUCT CODE: 3 PROBE NUMBER: Pb 3: Prem. Tk +ACM-3 Probe PROBE OFFSET: 0.00 INCHES FULL VOLUME: 19703 GALLONS DIAMETER: 117.8 INCHES TILT: 0.00 INCHES THERMAL COEFFICIENT: 0.000700 METER DATA PRESENT: ENABLED DELIVERY DELAY: 5 MINUTES GROSS TEST FAIL: ALARMS DISABLED PERIODIC TEST FAIL: ALARMS DISABLED ANNUAL TEST FAIL: ALARMS DISABLED GOST VOLUME CORRECTION: DISABLED --- LIMITS - TANK 3 --- MAX VOLUME: 19703 GALLONS HIGH PRODUCT: 95+ACU- DELIVERY OVERFILL: 90+ACU- DELIVERY LIMIT: 0+ACU- LOW PRODUCT: 600 GALLONS HIGH WATER WARNING: 1.00 INCHES HIGH WATER ALARM: 3.00 INCHES WATER ALARM FILTER LEVEL: LOW LEAK ALARM LIMIT: 15 GALLONS SUDDEN LOSS LIMIT: 50 GALLONS FUEL LOW TEMP LIMIT: -58.000 DEG F FUEL HIGH TEMP LIMIT: 140.000 DEG F --- ENVIRONMENTAL TESTS - TANK 3 --- TANK TEST METHOD: DISABLED --- PROFILE - TANK 3 --- TANK PROFILE: FOUR POINT +ACM- HEIGHT VOLUME +ACM- HEIGHT VOLUME --- ------ ------ --- ------ ------ 001 117.8 19703 003 58.9 9961 002 88.3 16051 004 29.4 3836 --- TANK 3 - CHART 1 --- LABEL: +ACoAKgAqACoAKg- TYPE: FOUR POINT SOURCE: USER ENTERED LAST CHANGE: 2022-08-20 STATUS: ACTIVE VOLUME ENTRY: TOTAL VOLUME +ACM- HEIGHT VOLUME +ACM- HEIGHT VOLUME --- ------ ------ --- ------ ------ 001 117.8 19703 003 58.9 9961 002 88.3 16051 004 29.4 3836 --- TANK 3 --- T3 SIPHON MANIFOLDED TO TANKS: NONE T3 LINE MANIFOLDED TO TANKS: NONE --- ACCUCHART - TANK 3 --- UPDATE SCHEDULE: NEVER CALIBRATION PERIOD: 14 DAYS WARNINGS: DISABLED MIN OPERATING LEVEL: 20+ACU- MAX OPERATING LEVEL: 70+ACU- --- HRM - TANK 3 --- WARNING LIMIT: 1 GALLONS ALARM LIMIT: 1 GALLONS MAXIMUM VOLUME LIMIT: 132 GALLONS +AAMAAQ- I70300 04/04/24 7:40 AM LIQUID MODEL SENSOR LABEL MODEL 1 Unld. T1 STP Sump Tri-State(Single Float) 2 Unld. T2 STP Sump Tri-State(Single Float) 3 Prem. T3 STP Sump Tri-State(Single Float) 4 Unld Tank1 Int Space Tri-State(Single Float) 5 Unld Tank2 Int Space Tri-State(Single Float) 6 Prem Tank3 Int Space Tri-State(Single Float) 7 Tri-State(Single Float) 8 Tri-State(Single Float) 9 Tri-State(Single Float) 10 Tri-State(Single Float) 11 Tri-State(Single Float) 12 Tri-State(Single Float) 13 Tri-State(Single Float) 14 Tri-State(Single Float) 15 Tri-State(Single Float) 16 Tri-State(Single Float) 17 Tri-State(Single Float) 18 Tri-State(Single Float) 19 Tri-State(Single Float) 20 Tri-State(Single Float) 21 Tri-State(Single Float) 22 Tri-State(Single Float) 23 Tri-State(Single Float) 24 Tri-State(Single Float) 25 Tri-State(Single Float) 26 Tri-State(Single Float) 27 Tri-State(Single Float) 28 Tri-State(Single Float) 29 Tri-State(Single Float) 30 Tri-State(Single Float) 31 Tri-State(Single Float) 32 Tri-State(Single Float) 33 Tri-State(Single Float) 34 Tri-State(Single Float) 35 Tri-State(Single Float) 36 Tri-State(Single Float) 37 Tri-State(Single Float) 38 Tri-State(Single Float) 39 Tri-State(Single Float) 40 Tri-State(Single Float) 41 Tri-State(Single Float) 42 Tri-State(Single Float) 43 Tri-State(Single Float) 44 Tri-State(Single Float) 45 Tri-State(Single Float) 46 Tri-State(Single Float) 47 Tri-State(Single Float) 48 Tri-State(Single Float) 49 Tri-State(Single Float) 50 Tri-State(Single Float) 51 Tri-State(Single Float) 52 Tri-State(Single Float) 53 Tri-State(Single Float) 54 Tri-State(Single Float) 55 Tri-State(Single Float) 56 Tri-State(Single Float) 57 Tri-State(Single Float) 58 Tri-State(Single Float) 59 Tri-State(Single Float) 60 Tri-State(Single Float) 61 Tri-State(Single Float) 62 Tri-State(Single Float) 63 Tri-State(Single Float) 64 Tri-State(Single Float) 65 Tri-State(Single Float) 66 Tri-State(Single Float) 67 Tri-State(Single Float) 68 Tri-State(Single Float) 69 Tri-State(Single Float) 70 Tri-State(Single Float) 71 Tri-State(Single Float) 72 Tri-State(Single Float) 73 Tri-State(Single Float) 74 Tri-State(Single Float) 75 Tri-State(Single Float) 76 Tri-State(Single Float) 77 Tri-State(Single Float) 78 Tri-State(Single Float) 79 Tri-State(Single Float) 80 Tri-State(Single Float) 81 Tri-State(Single Float) 82 Tri-State(Single Float) 83 Tri-State(Single Float) 84 Tri-State(Single Float) 85 Tri-State(Single Float) 86 Tri-State(Single Float) 87 Tri-State(Single Float) 88 Tri-State(Single Float) 89 Tri-State(Single Float) 90 Tri-State(Single Float) 91 Tri-State(Single Float) 92 Tri-State(Single Float) 93 Tri-State(Single Float) 94 Tri-State(Single Float) 95 Tri-State(Single Float) 96 Tri-State(Single Float) 97 Tri-State(Single Float) 98 Tri-State(Single Float) 99 Tri-State(Single Float)