Form Cn 1286 PDF Details

The CN 1286 form is a critical document for fuel facility owners and operators in Tennessee, playing a significant role in environmental protection and regulatory compliance. It acts as a monthly spill bucket inspection log, mandated by the State of Tennessee's Division of Underground Storage Tanks, a division of the Department of Environment and Conservation. The form outlines a structured protocol to ensure that spill buckets, which are designed to catch any overflow or leaks during the fuel dispensing process, are in good condition and can effectively contain spills. Facility owners and operators are required to conduct visual inspections of all spill buckets at least once a month and to record these inspections meticulously for at least the last twelve months. Not only does the form provide space for documenting the condition of up to six spill buckets, but it also allows for continuation on the reverse side or on additional sheets if a facility houses more than six spill buckets. The CN 1286 form helps in identifying any standing liquid, debris, or defects like cracks or torn connectors in spill buckets. Actions taken to address any deficiencies must be recorded, and in instances where defects could indicate released petroleum, such occurrences must be reported within 72 hours under Division regulations. Maintaining an up-to-date log of these inspections and having it available for state inspection underscores the commitment to environmental stewardship and adherence to regulations aimed at preventing contamination and protecting the community.

QuestionAnswer
Form NameForm Cn 1286
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesstate of tennessee spill bucket inspection log, basins, SB, utilized

Form Preview Example

 

STATE OF TENNESSEE

 

DIVISION OF UNDERGROUND

 

 

DEPARTMENT OF ENVIRONMENT AND

 

STORAGE TANKS

 

 

CONSERVATION

 

4TH Floor, L & C Tower

 

 

Monthly Spill Bucket Inspection Log

 

401 Church Street

 

 

 

Nashville, TN 37243-1541

 

 

 

 

 

 

 

 

 

 

INSTRUCTIONS

Tennessee Underground Storage Tank Rules require that visual inspections be made of all spill buckets on a monthly basis. In accordance with these rules, spill catchment basins shall be visually inspected by the owner and/or operator at least once a month to assure the integrity of the storage space provided for spill containment. A log of these inspections showing at a minimum the last twelve (12) months shall be maintained by the owner and/or operator.

This form shall be utilized to record the results of visual inspections of each spill bucket at the facility once each month.

A separate form should be used for each facility. The year the spill bucket inspections are performed shall be recorded in the space provided.

The front of this form has space for up to six spill buckets. If there are more than six spill buckets at this facility, use the back of this form or make additional copies.

If no standing liquid, debris or spill bucket defects (cracks, torn connectors, etc.) are noted, write “OK” in the appropriate column and row.

If any standing liquid, debris or spill bucket defects are noted, write “NOT OK” in the appropriate column and indicate what action was taken.

If there are spill bucket defects and indications of released petroleum, it must be reported as a suspected release within 72 hours in accordance with Division regulations.

Maintain the last 12 months of these inspections and have them available for state inspection.

UST FACILITY INFORMATION

NAME:

FACILITY ID #:

YEAR:

ADDRESS:

CITY:

ZIP:

 

 

 

 

 

 

 

 

 

CHECKED

 

Monthly Spill Bucket Visual Inspections

 

 

Action taken if

MM/DD/YY

Record condition in each block for the appropriate spill bucket (SB)

 

SB not OK

 

 

 

 

 

 

 

 

 

 

 

 

SB # 1

SB # 2

SB # 3

SB # 4

SB # 5

SB # 6

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CN-1286 (REV. 7-11)

CONTINUE ON REVERSE

RDA 2298

Use this side for additional spill buckets present at this location.

Please indicate spill bucket number in the space provided. Use additional sheets for this location if necessary.

CHECKED

 

Monthly Spill Bucket Visual Inspections

 

 

Action taken if

MM/DD/YY

Record condition in each block for the appropriate spill bucket (SB)

 

SB not OK

 

 

 

 

 

 

 

 

 

 

 

 

SB # ___

SB # ___

SB # ___

SB # ___

SB # ___

SB # ___

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CN-1286 (REV. 7-11)

2

RDA 2298

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