DERR-2024-006600

WESTECH EQUIPMENT
195 WEST 3900 SOUTH • P.O. BOX 57307 • SALT LAKE CITY, UTAH 84157-0307
801-266-2545 • TOLL FREE 800-433-8831 • 24 HOUR FAX [phone]

AUTOMATIC TANK GAUGE OPERATION INSPECTION
Facility Name: Holy Cross Hospital - Jordan Valley West Owner: Catholic Health Initiatives Colorado
Address: 3460 South Pioneer Parkway Address: 3460 South Pioneer Parkway
City, State, Zip: West Valley City, Utah 84120 City, State, Zip: West Valley City, Utah 84120
Facility I.D.#: 4000700 Phone #: [phone]
Testing Company: Westech Phone #: [phone] Date: 3/27/24
This procedure is to determine whether the automatic tank gauge (ATG) is operating properly. See PEI/RP1200 Section 8.2 for the inspection
procedure. This procedure is applicable to tank monitor stems the touch the bottom of the tank when in place.
Tank Number 1
Product Stored DSL
ATG Brand and Model TLS-300
1. Tank Volume, gallons 7,796
2. Tank Diameter, inches 92
3. After removing the ATG from the tank, it has been
inspected and any damaged or missing parts replaced? ☒Yes ☐No ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No
4. Float moves freely on the stem without binding? ☒Yes ☐No ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No
5. Fuel float level agree with the value programmed
into the console? ☒Yes ☐No ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No
6. Water float level agree with the value programmed
into the console? ☒Yes ☐No ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No
7. Inch level from the bottom of the stem when 90%
alarm is triggered? 76 5/8”
8. Inch level at which the overfill alarm activates
corresponds with the value programmed in the
gauge?
☒Yes ☐No ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No
9. Inch level from the bottom when the water float
first triggers an alarm? 2
10. Inch level at which the water float alarm activates
corresponds with the value programmed in the
gauge?
☒Yes ☐No ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No
If any answers in Lines 3, 4, 5, or 6 are "No" the system has failed the test.
Test Results ☒Pass ☐Fail ☐Pass ☐Fail ☐Pass ☐Fail ☐Pass ☐Fail
Comments: Battery OK
Tester’s Name Taber DeHart, UT-0394 Tester’s Signature

WESTECH EQUIPMENT
195 WEST 3900 SOUTH • P.O. BOX 57307 • SALT LAKE CITY, UTAH 84157-0307
801-266-2545 • TOLL FREE 800-433-8831 • 24 HOUR FAX [phone]

LIQUID SENSER FUNCTIONALITY TESTING
Facility Name: Holy Cross Hospital - Jordan Valley West Owner: Catholic Health Initiatives Colorado
Address: 3460 South Pioneer Parkway Address: 3460 South Pioneer Parkway
City, State, Zip: West Valley City, Utah 84120 City, State, Zip: West Valley City, Utah 84120
Facility I.D.#: 4000700 Phone #: [phone]
Testing Company: Westech Phone #: [phone] Date: 3/27/24
This procedure is to determine whether liquid sensors, located in the interstitial spaces of the UST systems, are able to det ect the presence of water and fuel. See
PEI/RP1200, Section 8.3 for the test procedure.
Sensor Location L-1 Tank L-2 Dock L-3 Trans
Product Stored DSL DSL DSL
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 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 test liquid, does the
sensor trigger an alarm? ☒ Yes ☐ No ☒ Yes ☐ No ☒ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No
When alarm is trigger, is the sensor
identified on the ATG console? ☒ Yes ☐ No ☒ Yes ☐ No ☒ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No
Any “No” answers indicate the sensor fails the test.
Test Results: ☒ Pass ☐ Fail ☒ Pass ☐ Fail ☒ Pass ☐ Fail ☐ Pass ☐ Fail ☐ Pass ☐ Fail ☐ Pass ☐ Fail ☐ Pass ☐ Fail
Comments: L-2 sensor replaced and retested on 3/28/24
Tester’s Name: Taber DeHart, UT-0394 Tester’s Signature