Attachment_C_Annual_Inspection__FitForServiceForm.pdf
PDF 174 KB Posted
- Attached to
- HAFE-FUEL MANAGEMENT SYSTEMS SERVICE
- Solicitation number
- 140P2125Q0140
About this file
This document is an Annual Inspection Certification form for Aboveground Storage Tanks (AST) from the Department of Environmental Protection (DEP), designed to certify that a storage tank is "Fit for Service" according to West Virginia Code of State Regulations (WV CSR 47-63). The form requires a qualified individual, such as a tank owner, operator, or certified inspector (P.E., API, or STI), to complete a comprehensive evaluation of the AST system, including associated equipment, leak detection systems, and secondary containment structures. The certifying individual must document any deficiencies, provide recommendations for addressing them, and confirm the tank meets applicable regulatory standards through a detailed inspection process.
The form provides spaces for recording critical information including the AST facility name, address, tank owner details, certifying individual's credentials, facility/owner's tank ID, DEP-issued tank label, and tank level classification. It includes two primary certification options: one for a qualified individual performing a tank evaluation, and another for a tank owner/operator certifying no significant changes since a previous professional inspection. The form is version V.7.22.2016 and serves as an official documentation method for maintaining the safety and compliance of aboveground storage tank systems under West Virginia regulations.
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Other files
| File | Type | Posted |
|---|---|---|
| Sol_140P2125Q0140_Amd_0002.pdf | ||
| Sol_140P2125Q0140_Amd_0001.pdf | ||
| Sol_140P2125Q0140.pdf | ||
| ATTACHMENT_A_Fuel_Monitoring_Systems_Locations.docx | DOCX document | |
| Attachment_D_Annual_Inspection_NotFitForService.pdf | ||
| Attachment_B_ATG_Testing_Report_Form.pdf |
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Text version
ANNUAL INSPECTION CERTIFICATION
Aboveground Storage Tank
Is Fit for Service
V.7.22.2016
☐ I am a qualified individual as described in WV CSR 47‐63‐5.2 and I have performed a tank evaluation on the above AST system. I certify the tank system meets applicable standards established by WV CSR 47‐63.
☐ I am the tank owner, operator, or qualified representative of the tank owner or operator, and have performed a tank evaluation on the above AST system. I certify there is no obvious change to the tank system that would cause this tank to become not‐fit for service since it was certified by a PE, API or STI inspector on
_______________________ (date). This certification meets the requirements set in WV CSR 47‐63‐5.2.b.3 to certify annual inspections in intervening years between the evaluations required by a PE, API or STI inspector.
In accordance with the WV CSR 47‐63‐5.2, I have documented all deficiencies and/or changes in the tank system found during the inspection, in writing, and provided my recommendations, including a proposed schedule, for abating the deficiencies and submitted them with this form.
I certify that I have personally examined and/or am familiar with the inspection performed on the AST system listed above, including its associated equipment, leak detection system and secondary containment structure, and that based on my direct knowledge that the AST listed above is Fit for Service.
Signature of Certifying Individual Date Signed
P.E. Registration #, STI Certification # or Registration/Certification Expiration Date API
Certification # (if applicable) (if applicable)
AST Facility Name
Address
City, State, Zip
Tank Owner Name
Telephone Number
Email Address
Certifying Individual
Address
City, State, Zip
Telephone Number
Email Address
Facility’s/Owner’s Tank ID
DEP Issued Tank Label
DEP Determined Tank Level Level 1 tank ☐ Level 2 tank ☐
Attachment C
| AST Facility Name: |
| Address: |
| City State Zip: |
| Tank Owner Name: |
| Telephone Number: |
| Email Address: |
| Certifying Individual: |
| Address_2: |
| City State Zip_2: |
| Telephone Number_2: |
| Email Address_2: |
| FacilitysOwners Tank ID: |
| DEP Issued Tank Label: |
| certify annual inspections in intervening years between the evaluations required by a PE API or STI inspector: |
| Date Signed: |
| PE Registration STI Certification or: |
| RegistrationCertification Expiration Date API: |
| Check Box1: Off |
| Check Box11: Off |
| Check Box12: Off |
| Check Box13: Off |
File details come from the government source that posted it. Updated .