Quarterly Inspection Report – Fill Out and Use This PDF

For UST System Inspections

Facility Name:

Facility ID:

THIS QUARTERLY INSPECTION IS IN ADDITION TO ALL OTHER MONTHLY RELEASE DETECTION AND TESTING REQUIREMENTS

UST Quarterly Inspection Equipment Items (place check mark in last column if unusual conditions (UC) exist)

CHECKED

N/A

UC

Section A.

Tank Leak Detection Records (Circle applicable number)

1.

Automatic Tank Gauge

Monthly passing print out tape

2.

Interstitial Sensors

Monthly status record of normal or equivalent - Annual functional test

Last tested:________

Test due:_________

3.

S.I.R. (Includes Warren Rogers)

Monthly status report normal or equivalent

4.

Manual Tank Gauging < 600 gal.

Weekly stick measurements with monthly reconciliation

5.

Vapor/Groundwater Monitoring

Monthly log with date, results and inspectors initials

6.

Water in Tank

Monitor ATG for water alarm or check tank utilizing gauge stick and water paste

Section B.

Tank Component Inspection

1.

Tank Monitoring System

Ensure system has power and is in a normal status with no alarms (daily)

2.

Submersible Sump Covers

Ensure all covers are present, in good condition and seated firmly

3.

Submersible Sump

Ensure no water is in submersible sump that contains interstitial sensors

If piping is single wall and corrosion prevention is installed, water is allowed

4.

Electrical

Ensure junction boxes are intact and no obvious wire breaks are visible

Section C.

Piping Leak Detection Records (Circle applicable number)

1.

Interstitial Sensors

Monthly status record of normal or equivalent - Annual functional test

Last tested:________

Test due:_________

2.

Mechanical Line Leak Detector

Annual precision test of lines and functionality test of leak detector

Last tested:________

Test due:_________

3.

Electronic Line Leak Detector

If proof of annual 0.1 gph system leak test is performed, a functionality test of

the leak detector is required only - If proof is not available a precision line test

will also have to be performed

Last tested:_______ Test due:_______

Section D.

Piping Component Inspection (Circle applicable number)

1.

Pressurized piping components

Ensure line leak detector is in place, if interstitial sensors are used, ensure they

are positioned at the lowest portion of the submersible and dispenser sump

2.

American Suction

Ensure monthly monitoring is in place

3.

Product Piping

Inspect for obvious leaks, deformations, cracks or other abnormalities

Section E.

Corrosion Protection Records (Circle applicable number)

1.

Impressed Current System

Monthly log with date, initials of inspector, hour, volt, amp and power on

verification - Annual system test: Last tested:_________ Test due:_________

2.

Sacrificial Anode System

System must be tested every 3 years: Last tested:________ Test due:________

3.

Internal Lining

Must be inspected every 5 years:

Last tested:_________ Test due:_________

Section F.

Corrosion Component Inspection (Circle applicable number)

1.

Impressed Current System

Ensure rectifier has power and power light functions, observe and record volt,

amp and hour meter readings

2.

Sacrificial Anodes

If anodes and connections are visible in submersible or dispenser sumps,

observe for obvious connection breaks of wiring from steel components

Section G.

Spill Protection

1.

Spill Protection Equipment

Ensure spill containment is in place, clean, dry & no obvious cracks/tears (daily)

Section H.

Overfill

1.

Automatic Shutoff

Ensure device is in place and free of restrictive items

2.

Overfill Alarm

Ensure device is in place and test function operates properly

Section I.

Dispensers and Emergency Shut-Offs

1.

Hose and Nozzle Components

Observe for obvious leaks, cracks & deformations. Ensure breakaway is installed

2.

Under dispenser

Ensure shear valve is in place and properly anchored. Observe for obvious leaks

Ensure interstitial sensors if installed are positioned at the lowest portion

Observe for obvious open electrical junction boxes or broken wiring

Section J.

Emergency Shut-Off

1.

Emergency Shut-Off

Ensure emergency shut-offs are accessible and have no obvious damage

Last tested:_________ Test due:_________

Section K.

Emergency Actions

1.

System Alarms

Ensure any alarms have been reported as required by facility operations plan

2.

Spills, Leaks or Release

Ensure any release has been reported as required by facility operations plan