Appendix A - Inspection Forms and Checklists.pdf

Department of Licensing and Regulatory Affairs, Bureau of Fire Services, Storage Tank Division P.O. Box 30033, Lansing, MI 48909 Phone 517-241-8847

UNDERGROUND STORAGE TANK OPERATIONAL FACILITY INSPECTION FORM

This information is required under Part 211, Underground Storage Tank Regulations, of the Natural Resources and Environmental Protection Act, Act 451 of the Public Acts of 1994.

Any owner who knowingly fails to notify or submits false information shall be subject to a misdemeanor punishable by imprisonment for not more than 6 months or fines of not more than $500.00 or both and/or a civil fine not to exceed $5,000.00 for each underground storage tank system for each day of violation.

INITIAL BESIDE EACH STATEMENT THAT APPLIES:

__________ Verification of proper tank registration including proper certificate posting.

__________ Verification of functional status of corrosion protection equipment if required and present, including proper cathodic protection system readings in the case of impressed current corrosion protection systems.

__________ Verification of functional status of release detection equipment including reviewing the alarm history report for the previous month, and checking that each alarm condition was documented and responded to appropriately. A copy of the alarm history report or log, along with documentation describing action taken in response to any alarm(s), shall be attached to the monthly report.

__________ Results of inspection for the presence of product, water, or debris in the spill containers and verifying the functional status of leak prevention equipment, such as spill and overflow.

__________ Results of inspection for the presence of product, water, or debris in under dispenser containment areas or containment sumps, and checking that the monitoring equipment in these containment areas is located in the proper position to detect a leak at the earliest possible opportunity.

__________ Verification that any required testing, monitoring, or periodic inspections of the UST systems have been completed, including documentation of the dates those activities occurred. (i.e.: Impact/fire safety valve, mechanical leak detector, annual piping testing, etc.)

__________ Verification of the presence of all required records necessary to substantiate operational compliance.

__________ Notice to the Class A operator of any deficiencies or noncompliance with any of the above items and any recommendations made to remedy any deficiencies or noncompliance discovered during the site visit, including any prior recommendations that have not been addressed within 60 days or another time frame determined by the department.

Provide an explanation for any of the above statements left incomplete._____________________________________________

I attest that this inspection was done in accordance with Section 280.13(c)(1) & (2) of the Michigan Underground Storage Tank Rules (MUSTR). As a certified Class B operator, I am familiar with the information submitted in this report and all attached documents. Based upon my reasonable inquiry of those individuals responsible for obtaining the information, I believe the information in this report is, to the best of my knowledge, true, accurate and complete.

Print name & official title of Designated Class B Operator Signature of Designated Class B Operator Date

BFS-4027 (Rev 9/15)

FACILITY NAME

FACILITY ID NUMBER

FACILITY STREET ADDRESS (P.O. BOX NOT ACCEPTABLE) CONTACT PERSON AREA CODE & TELEPHONE NUMBER

CITY COUNTY STATE

MI

ZIP CODE

OWNER NAME OWNER ADDRESS AREA CODE & TELEPHONE NUMBER

CITY STATE ZIP CODE

INSTRUCTIONS: Section 280.13(c)(1) & (2) of the Michigan Underground Storage Tank Rules (MUSTR) requires owners and operators of underground storage tanks (UST) to perform required checks of their UST systems and to attest to their findings. This form, a form acceptable to the department or an electronic form must be completed by the Class B operator and then provided to the Class A operator. The Class B operator shall alert the Class A operator of any conditions discovered during the inspection that may require follow-up actions. The completed form must be maintained (kept) by the Class A operator for at least 3 years. The form is NOT submitted to the Bureau of Fire Services, Storage Tank Division. Please direct questions to the Storage Tank Division, at 517-241-8847.

N/A Tank 1 Tank 2 Tank 3 Tank 4 Tank 5 Tank 6

If any problem is found, contact: Contact Information:

Tank Vents Vent cap present, vent pipe solidly supported and vertical Stage I Vapor Recovery

Manual Interstitial Monitoring for Piping (MIMPT) Tank-top sump inspected & no liquid found

Manual Interstitial Monitoring for Tanks

(MIMT)

Steel tank: interstitial space checked & found dry

Tank Gauge Stick Tank gauge stick can be clearly read, is not warped or broken Check for Water

Fiberglass tank: Interstitial space checked & found dry

No water present in the tank

Drop Tube Standard drop tube smooth, no ragged edges, in good condition Top edge of coaxial drop tube smooth, round, slightly below the top edge of the fill pipe

All Tanks

Spill-Containment Manhole Drain valve in spill-containment manhole in good condition

All covers present, in good condition, seated firmly on the correct tank

Grade-Level Covers

N/A

Instructions: Mark each tank where no problem is observed with a "Yes" - If certain equipment is not required and/or not present, mark checklist in the N/A column - If a defect is found, mark the checklist with an "No", describe the problem in the DEFICIENCIES section, and notify the Class B person.

If spill-containment manhole is present, no cracks, bulges, or holes

If spill-containment manhole is present, no dirty, no trash, water, or product

Record volt & amp readings, readings consistent with previous months

N/A

DESCRIBE ANY DEFICIENCIES HERE:

Observation and Monitoring Wells Observation well cover is properly identified and secured

Corrosion Protection

Impressed-Current Cathodic Protection Record hour meter reading (if present). Reading increases by about 700 hours each month

Two-Point (Dual-Point) Vapor Recovery

Cover present, colored orange, seated firmly at grade, not broken, cracked or chipped

Vapor recovery cap present, seals tightly Poppet of vapor recovery adaptor seals tightly

Fiberglass tank: level of monitoring fluid within normal range For steel & fiberglass tanks, vacuum level is within tolerances

Manual Groundwater (GWM) Or Soil Vapor Monitoring (SVM)

Wells sampled and results pass

Inventory reconciled & within the company or regulatory standard

Inventory Control (IC)

Monthly Piping Leak Test (MPLT) Passing tank test report printed & properly filed

Statistical Inventory Reconciliation (SIR) This month's inventory analyzed; last month's results passed and available for inspection

Automatic Tank Gauge (ATG) Passing tank test report printed & properly filed Continuous Interstitial Monitoring (CIM) Sensor status report printed and properly filed

Daily Inspections Complete daily checklist & Compare to previously completed daily checklists

Leak Detection Recordkeeping

Circle method of tank leak detection: ATG, CIM, SIR, IC, GWM, SVM, MIMT Circle method of piping leak detection: CIM, CMPT, SIR, GWM, SVM, MIMP

Category Description Product Type:

QUARTERLY UNDERGROUND STORAGE SYSTEM INSPECTION CHECKLIST

Facility ID Facility Name/ Address Class A/B Operator Date

PEI/RP900

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ID#: ANNUAL DISPENSER INSPECTION CHECKLIST Date:

Category Description PEI/RP900 N/A Disp 1 Disp 2 Disp 3 Disp 4

Initial Fuel Dispenser Inspection 7.5

All Dispensers

1.5.7 yrd dna naelc era stnenopmoc resnepsid llA

2.5.7 yrd si pmus ,tneserp si pmus resnepsid fI

Fuel Dispenser Inspection 7.6

All Dispensers

1.6.7 gnikael fo sngis on wohs sgnittif dna gnipip elbisiV

Piping in good condition 7.6.2

Dispenser containment sump fr 5.6.7 sirbed dna hsart fo ee

Junction box(es) have covers, not corroded; conduit and intrinsically safe wiring in good condition 7.6.8

Flexible connectors not frayed, twisted, kinked or bent beyond manufacturer specifications 7.6.9

Shear valves operate freely and close completely TEST DATE: 7.6.15 Stage II piping functional or else capped and sealed at an elevation lower than the fuel dispenser island 7.6.16

Dispensers Without Sumps

Flex connectors and other metallic product piping are not in contact with soil or water or are cathodically protected 7.6.17

Dispensers With Sumps

4.6.7 ylreporp fo desopsid dna devomer tcudorp ro retaw ynA

6.6.7 stcefed rehto ro ,seglub ,seloh ,skcarc fo eerf pmuS

7.6.7 deruces dna tcatni sgnittif noitarteneP Piping interstitial space open to the dispenser sump or dispenser pan (open double-walled piping system only) 7.6.21

Piping interstitial space closed to the dispenser sump (closed double-walled piping system only) 7.6.22 Dispensers With

Single-Walled Sumps

Single-walled sump tested for integrity every 3 years TEST DATE: 7.6.18

Dispensers With Double-Walled

Sumps

If not continuously monitored or inspected annually, double-walled sump tightness tested every 3 years 91.6.7 :ETAD TSET

DESCRIBE ANY DEFICIENCIES HERE:

APPENDIX A-2: SAMPLE FORM FOR ANNUAL DISPENSER INSPECTION CHECKLIST

Go to www.pei.org/RP900 for an electronic version of this form.

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ID#: ANNUAL FILL CONTAINMENT SUMP INSPECTION CHECKLIST Date:

Category Description PEI/RP900 N/A Tank 1 Tank 2 Tank 3 Tank 4

Fill Sump 7.6

Fill Containment Sump

4.6.7 ylreporp fo desopsid dna devomer tcudorp ro retaw ynA

1.6.7 gnikael fo sngis on wohs sgnittif dna gnipip elbisiV

Piping in good condition 7.6.2

3.6.7 tneserp ton noisorroc evissecxE

5.6.7 sirbed dna hsart fo eerf pmuS

Sump is free of cracks, holes, bul 6.6.7 stcefed rehto ro seg

7.6.7 deruces dna tcatni sgnittif noitarteneP Junction box(es) have covers, not corroded; conduit and intrinsically safe wiring in good condition 7.6.8

Flexible connectors not frayed, twisted, kinked or bent beyond manufacturer specifications 7.6.9

Piping interstitial space open to the fill sump (open double-walled piping system only) 7.6.20

Piping interstitial space closed to the fill sump (closed double-walled piping system only) 7.6.22

Sump lid, gasket and seals pres 32.6.7 noitidnoc doog ni dna tne

Manhole cover at grade in good condition, does not touch sump cover, all bolts present, handles and lift mechanism in good condition (as applicable) 7.6.24

Single-Walled Fill Sump Single-walled sump tested for integrity every 3 years TEST DATE: 7.6.18

Double-Walled Fill Sump

If not continuously monitored or inspected annually, double-walled sump tightness tested every 3 years TEST DATE: 7.6.19

APPENDIX A-2: SAMPLE FORM FOR ANNUAL FILL CONTAINMENT SUMP INSPECTION CHECKLIST

Recom m ended Practices for the Inspection and M aintenance of UST System s aP tsilkcehC noitcepsnI eciveD noitceteD kaeL launnA 009 PR IEP ge ___ of ___

ID#: ANNUAL LEAK DETECTION DEVICE INSPECTION CHECKLIST Date:

Category Description PEI/RP900 N/A Tank 1 Tank 2 Tank 3 Tank 4

Leak Detection Device. Describe location (e.g., interstitial, STP, fill, dispenser) on this row: 7.7

Liquid Sensor

Sensor tested and functio 1.7.7 :ETAD TSET lan Sensor properly mounted at the bottom of the containment sump or pan (containment sump or pan sensor only) 7.7.3

Sensor properly mounted at the bottom of double-walled tank (double-walled tank sensor only) 7.7.4

Discriminating Sensor

Sensor tested and functio 1.7.7 :ETAD TSET lan Sensor properly mounted at the bottom of the containment sump or pan (containment sump or pan sensor only) 7.7.3

Sensor properly mounted at the bottom of double-walled tank (double-walled tank sensor only) 7.7.4

Hydrostatic Sensor

Sensor tested and functio 1.7.7 :ETAD TSET lan

5.7.7 denoitisop ylreporp rosnes citatsordyH

Vacuum/Pressure Sensor

Sensor tested and functio 1.7.7 :ETAD TSET lan

Alarm sounds when pressure or vacuum is released TEST DATE: 7.7.2 Entire interstitial space under pressure or vacuum (closed double-walled piping system only) TEST DATE: 7.7.7

Visually Monitored

Double-Walled Sump

Leak detection device is withi 6.7.7 stimil dednemmocer n

Dispenser Pan Float Mechanism

Sensor tested and functio 1.7.7 :ETAD TSET lan Dispenser pan float mechanism free to move and properly adjusted TEST DATE: 7.7.8

APPENDIX A-2: SAMPLE FORM FOR ANNUAL LEAK DEVICE INSPECTION CHECKLIST

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ID#: ANNUAL STP INSPECTION CHECKLIST Date:

Category Description PEI/RP900 N/A Tank 1 Tank 2 Tank 3 Tank 4

Submersible Turbine Pump (STP)

All STP

1.6.7 gnikael fo sngis on wohs sgnittif dna gnipip elbisiV

Piping in good condition 7.6.2

3.6.7 tneserp ton noisorroc evissecxE

5.6.7 sirbed dna hsart fo eerf pmuS

Junction box(es) have covers, not corroded; conduit and intrinsically safe wiring in good condition 7.6.8

Flexible connectors not frayed, twisted, kinked or bent beyond manufacturer specifications 7.6.9 Mechanical line leak detector properly vented, vent tube not kinked or twisted, vent tube fittings intact and tightened 7.6.10

Mechanical line leak detector passes 3.0 gallons per hour (gph) test TEST DATE: 7.6.11

Electronic line leak detector (ELLD) passes 3.0 gph test TEST DATE: 7.6.12

ELLD passes 0.2 gph test TEST DATE: 7.6.13

ELLD passes 0.1 gph test TEST DATE: 7.6.14 Manhole cover at grade in good condition, does not touch sump cover, all bolts present, handles and lift mechanism in good condition (as applicable) 7.6.24

STP: No Containment

Sump

Submersible pump head, flex connector(s) and other metallic product piping are not in contact with soil or water or are cathodically protected 7.6.17

STP: In Containment

Sump

4.6.7 ylreporp fo desopsid dna devomer tcudorp ro retaw ynA

Sump is free of cracks, holes, bul 6.6.7 stcefed rehto ro seg

7.6.7 deruces dna tcatni sgnittif noitarteneP

Piping interstitial space open to the STP sump (open double-walled piping system only) 7.6.20

Piping interstitial space closed to the STP sump (closed double-walled piping system only) 7.6.22

Sump lid, gasket and seals pres 32.6.7 noitidnoc doog ni dna tne STP: In

Single-Walled Containment

Sump

Single-walled sump tested for integrity every 3 years TEST DATE: 7.6.18

APPENDIX A-2: SAMPLE FORM FOR ANNUAL STP INSPECTION CHECKLIST – Page 1

Recom m ended Practices for the Inspection and M aintenance of UST System s

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Category Description PEI/RP900 N/A Tank 1 Tank 2 Tank 3 Tank 4

STP: In Double-Walled

Containment Sump

If not continuously monitored or inspected annually, double-walled sump tightness tested every 3 years TEST DATE: 7.6.19

APPENDIX A-2: SAMPLE FORM FOR ANNUAL STP INSPECTION CHECKLIST – Page 2

Recom m ended Practices for the Inspection and M aintenance of UST System s ___ fo ___ egaP tsilkcehC noitcepsnI launnA 009 PR IEP

ANNUAL UST SYSTEM INSPECTION CHECKLIST

Facility ID# Facility Name/Addre utangiS naicinhceT deifilauQ ss re Date

If any problem is found, contact: Contact information:

Category Description PEI/RP900 N/A Tank 1 Tank 2 Tank 3 Tank 4

Monthly Inspections

Complete monthly checklist and compare to previously completed monthly checklists 7.4.1

2.4.7 etauqeda dnuof dna deweiver snoitcepsni ylhtnoM

ATG Manhole 7.8

ATG Manhole

Cap in good condition, seals tightly, hole sealed where probe wire goes through 7.8.1

2.8.7 noitidnoc doog ni eriw dna delaes secilps eriW

Junction box has cover, not corroded; intrinsically safe wiring in good condition 7.8.3

No exposed wires 7.8.4 Probe and floats in good condition, both floats present and move freely (mag probe) TEST DATE: 7.8.5

Verify functionality of ATG p 6.8.7 :ETAD TSET ebor

7.8.7 noitidnoc doog ni revoc elohnaM

Adequate clearance between ATG grade-level cover and below-grade components 7.8.8

Fill Area 7.9

Drop Tube Drop tube extends to within 6 inches of the tank bottom (if no flow diffuser present) 7.9.1 Vapor Recovery

Adaptor Poppet of Stage I vapor recovery adaptor (also known as a “dry break”) moves freely, seals tightly 7.9.2

Single-Walled Spill Containment

Manhole

Single-walled spill containment manhole tightness tested within last 3 years TEST DATE: 7.9.3

Double-Walled Spill Containment

Manhole

Double-walled spill containment manhole tightness tested within last 3 years OR inspected monthly TEST DATE: 7.9.4

Overfill Prevention 7.10 Drop Tube

Shutoff (Flapper Valve)

Drop tube shutoff valve passes inspection EVALUATION DATE: 7.10.1.1

For drop tube shutoff valves in diesel tanks, excessive corrosion not present 7.10.1.2

APPENDIX A-2: SAMPLE FORM FOR ANNUAL UNDERGROUND STORAGE SYSTEM INSPECTION CHECKLIST – Page 1

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Category Description PEI/RP900 N/A Tank 1 Tank 2 Tank 3 Tank 4

Ball Float Valve

1.2.01.7 detcepsni dna devomer eb nac taolf llaB

2.2.01.7 :ETAD NOITAULAVE noitcepsni sessap evlav taolf llaB

For ball float valves in diesel tanks, excessive corrosion not 3.2.01.7 tneserp

Overfill Alarm Overfill alarm pas ETAD NOITAULAVE noitcepsni ses : 7.10.3.1

Leak Detection 7.11

ATG Console

LAVE noitcepsni launna sessap GTA UATION DATE: 7.11.1.1

Console has no active warni 2.1.11.7 smrala ro sgn

Alarm history shows no recurri 3.1.11.7 smrala kael gn

Verify in-tank leak detection tests are being completed (if used for leak detection) 7.11.1.4 Verify correct set-up parameters for electronic line leak detector (if present) VERIFICATION DATE: 7.11.1.5

Verify piping leak detection tests are being completed (if used for leak detection) 7.11.1.6

Electronic Leak Detection Monitor Leak monitoring console is operational and has no active warnings or alarms 7.11.2.1

Line Tightness Testing

If pressurized piping has been tested in the last year, review the results and verify that the test passed TEST DATE: 7.11.3.1

If suction piping has been tested within the last 3 years, review the results and verify that the test passed TEST DATE: 7.11.3.2

ELLD has conducted a 0.1 gph test in the last year TEST DATE: 7.11.3.3

Under Pump Check Valve

(Suction Pump)

Below-grade piping operates at les 7 erusserp cirehpsomta naht s .11.4.1

Below-grade piping slopes contin .4.11.7 knat eht ot kcab ylsuou 2

There is only one check valve, and it is located as close as practicable to the suction pump 7.11.4.3

Tank Tightness Testing

1.5.11.7 ssel ro dlo sraey 01 si knaT If a tank test has been conducted within the last 5 years, review the results and verify that the test passed TEST DATE: 7.11.5.2

Statistical Inventory

Reconciliation

(SIR)

SIR results for the previous 1.6.11.7 "ssap" era shtnom 21

APPENDIX A-2: SAMPLE FORM FOR ANNUAL UNDERGROUND STORAGE SYSTEM INSPECTION CHECKLIST – Page 2

Recom m ended Practices for the Inspection and M aintenance of UST System s ___ fo ___ egaP tsilkcehC noitcepsnI launnA 009 PR IEP

Category Description PEI/RP900 N/A Tank 1 Tank 2 Tank 3 Tank 4

Continuous Soil Vapor Monitoring 1.7.11.7 :ETAD TSET detset ecived gnisneS

Continuous Ground-water Monitoring 1.8.11.7 :ETAD TSET detset ecived gnisneS

Corrosion Protection 7.12 Galvanic Cathodic

Protection

Verify that cathodic protection testing of all metallic components in contact with soil or water has been conducted within the past 3 years and the test passed

TEST DATE: 7.12.1.1

Impressed Current Cathodic

Protection

Verify that cathodic protection testing has been conducted within the past 3 years and the test passed TEST DATE: 7.12.2.1

No exposed wires 7.12.2.2

Tank Lining Lining inspected as required and in good condition TEST DATE: 7.12.3.1

Miscellaneous Inspection Items 7.13 Tank Pad &

Pavement Concrete or asphalt over or near tanks is level, no significant 1.1.31.7 skcarc

Stage II Liquid Collection Points Cap in good condition, fits tightly, little or no liquid in bot 1.2.31.7 mot

Stage I Testing Verify that Stage I testing has been conducted and test results are passing TEST DATE: 7.13.3.1

Stage II Testing Verify that Stage II testing has been conducted and test results are passing TEST DATE: 7.13.4.1

Site Diagram Site diagram accurately reflects the site conditio 1.5.31.7 sn

Instructions: Mark each tank where no problem is observed with a checkmark: √ If certain equipment is not required and / or not present, mark checklist in the N/A column. If a defect is found, mark the checklist with an “X,” describe the problem in the “DEFICIENCIES” section, and notify the appropriate person. Refer to the section listed in the “PEI/RP900” column for additional information. Refer to PEI RP500, Recommended Practices for Inspection and Maintenance of Motor Fuel Dispensing Equipment, for inspection procedures that apply to fuel dispensing equipment.

APPENDIX A-2 SAMPLE FORM FOR ANNUAL UNDERGROUND STORAGE SYSTEM INSPECTION CHECKLIST – Page 3