Exhibit B - Modification Inspection Report.docx

BPM005267 Exhibit B

UST MODIFICATION INSPECTION REPORT

ARIZONA DEPARTMENT OF ENVIRONMENTAL QUALITY

1110 West Washington Street, Phoenix, Arizona 85007 ADEQ Help Line (In-State Only) 1-800-234-5677

☐ Overfill Prevention Device ☐ STP Sump(s) ☐ Piping ☐ Dispensers ☐ UDC Sumps(s) ☐ Entry Boots ☐ Other:

Reason for Modification

Closure of Existing System Components Date

Arrival Time

Departure Time

Pre-Burial Date

Arrival

Departure Time

Final Installation Date

Arrival

Departure Time

FACILITY INFORMATION

Facility Name

Facility Address

City & ZIP

UST Owner Name

Mailing Address

Owner Contact Name

Contact Title

Owner Contact Email

Contact Phone #

SERVICE PROVIDER INFORMATION

Service Provider Company

Service Provider Address

Primary Contact

Position

Email Address

Primary Phone #

ENVIRONMENTAL COMPANY INFORMATION

Environmental Company

Company Address

Registered Professional

Office Phone #

Registered Professional Email

Primary Phone #

On-Site Rep Name / Title

On-Site Rep Email Address

Primary Phone #

Additional On-Site Personnel

AZDEQ REPRESENTATIVE INFORMATION

AZDEQ Representative

AZDEQ Rep Title

Accompanied by

Title

UST INFORMATION - Complete one column for each compartment

Tank ID #

☐ Product Lines ☐ Siphon Line ☐ Vent lines ☐ Product Lines ☐ Siphon Line ☐ Vent lines ☐ Product Lines ☐ Siphon Line ☐ Vent lines ☐ Product Lines ☐ Siphon Line ☐ Vent lines ☐ Product Lines ☐ Siphon Line

Location of Manifold

Tank Manufacturer

Complete for the installation or replacement of SPILL BUCKET(s) & ANCILLARY EQUIPMENT Complete one column for each containment sump

Tank ID #

Manufacturer & Model

type of gauge

Size (Gallons)

Fill Cap / Adapter Manufacturer & Model

ball float and flapper?

Cap / Adapter Manufacturer & Model

REPLACEMENT SPILL BUCKET & ANCILLARY EQUIPMENT

Manufacturer & Model

type of gauge

Size (Gallons)

Reference: PEI/RP100-17, Section 7.2: SPILL CONTAINMENT

Spill Containment Integrity Test Date

POST-test Height

ball float and flapper?

Cap / Adapter Manufacturer & Model

COMMENTS

Complete for the installation or replacement of STP SUMP(s) & ANCILLARY EQUIPMENT Complete one column for each STP sump

Tank ID #

STP Containment Sump Manufacturer

STP Containment Sump Model

Type of annular space

Type of IM sensor

Entry Boot Manufacturer

REPLACEMENT STP CONTAINMENT SUMP & ANCILARY EQUIPMENT

STP Containment Sump Manufacturer

STP Containment Sump Model

Type of annular space

Manufacturer of IM sensor

If Double Wall, Model of IM sensor

Entry Boot Manufacturer

Entry Boot Model

Adhesive Manufacturer & Product Name

STP Containment Hydrostatic Test Date

POST-test Height

Tank ID #

STP Turbine Model

COMMENTS regarding STP SUMP and ANCILLARY EQUIPMENT

Complete for the replacement or addition of PIPING Complete one column for each PRODUCT

Tank ID #

(e): Length of piping after modification/s:

(a) – (b) + (c) + (d)

(f): total length for replacement and new piping: (c) + (d)

(g): Percentage of new piping to total linear feet of all connected piping:

divide (f) by (a)

If the Existing Piping System Type is pressurized, and the Existing Piping Type is underground, and the Existing Piping Wall Type is single wall, and (g) is 50% or more, the existing piping must be brought into compliance with the secondary containment and release detection requirements for hazardous substance underground storage tank systems in 40 Code of Federal Regulations section 280.42 and the interstitial monitoring requirements in 40 Code of Federal Regulations section 280.43, subsection G

A.R.S. 49-1009 Tank Performance Standards (C) – Beginning January 1, 2009, a personal shall not install a new piping component that is twenty-five percent or more of the total linear footage of all connected piping of the underground storage tank unless all connected piping of the underground storage tank that conveys a regulated substance under pressure is brought into compliance with the secondary containment and release detection requirements for hazardous substance underground storage tank systems in 40 Code of Federal Regulations section 280.42 and the interstitial monitoring requirements in 40 Code of Federal Regulations section 280.43, subsection G. [THIS REQUIREMENT WAS UPDATED IN AZ HB 2043.]

AZ HB 2043 requires an underground storage tank system (UST) to comply with certain federal performance standards in effect on January 1, 2020, and requires the following to comply with the secondary containment performance standards for new USTs and release detection requirements for interstitial monitoring in 40 Code of Federal Regulations Section 280.43(g) and in effect on January 1, 2020:

(a) newly installed USTs; and

(b) any newly installed piping component that is 50% or more of the total linear footage of all connected piping in the UST and conveys a regulated substance.

NEW or REPLACEMENT PIPING INFORMATION

Adhesive (Glue) Brand

PRIMARY

Test Pressure at START of Pressure Test

PRIMARY

Test Pressure at END of Pressure Test

PRIMARY

Pressure Test Results

SECONDARY

Test Pressure at START of Pressure Test

SECONDARY

Test Pressure at END of Pressure Test

SECONDARY

Pressure Test Results

Complete for the addition or replacement of DISPENSERS or UNDER-DISPENSER CONTAINMENT SUMPS

EXISTING DISPENSER EQUIPMENT (BEFORE modification)

Dispenser Manufacturer (if available)

Dispenser Model

UDC Sump Model

Piping Connector Mfgr

Shear Valve Manufacturer

Shear Valve Model

Quantity of Shear Valves

40 CFR 280.20(f) Dispenser systems. Each UST system must be equipped with under-dispenser containment for any new dispenser system installed after April 11, 2016.

(1) A dispenser system is considered new when both the dispenser and the equipment needed to connect the dispenser to the underground storage tank system are installed at an UST facility. The equipment necessary to connect the dispenser to the underground storage tank system includes check valves, shear valves, unburied risers or flexible connectors, or other transitional components that are underneath the dispenser and connect the dispenser to the underground piping.

(2) Under-dispenser containment must be liquid-tight on its sides, bottom, and at any penetrations. Under-dispenser containment must allow for visual inspection and access to the components in the containment system or be periodically monitored for leaks from the dispenser system.

NEW or REPLACEMENT DISPENSER EQUIPMENT (AFTER modifications)

Dispenser Manufacturer

Dispenser Model

UDC Sump Model

Entry Boot Manufacturer

Entry Boot Model

Adhesive Manufacturer & Product Name

Piping Connector Mfgr

Piping Connector Model

Shear Valve Manufacturer

Shear Valve Model

Quantity of Shear Valves

COMMENTS

‘ BGS

From ‘ BGS to

‘ BGS

‘ BGS

ppm

‘ BGS

‘ BGS

ppm

‘ BGS

☐ Stained Soil ☐ Odor ☐ Elevated PID reading ☐ Vapor ☐ Sheen ☐ Free Product on Groundwater

☐ NONE

☐ Stained Soil ☐ Odor ☐ Elevated PID reading ☐ Vapor ☐ Sheen ☐ Free Product on Groundwater

UDC & TRANSITION SUMP HYDROSTATIC TESTING

Reference: PEI/RP100-17, Section 8.5.4: CONTAINMENT SUMP TESTING.

SUMP Designation

Hydro Test Date

POST-test Height

Hydro Test Date

POST-test Height

Hydro Test Date

POST-test Height

Hydro Test Date

POST-test Height

RELEASE DETECTION INFORMATION

Per R18-12-220. Performance Standards for New UST Systems (A) Owners and operators of a new UST system shall meet the requirements described in this Section in order to prevent releases due to structural failure, corrosion, or spills and overfills for as long as the UST system is used to store regulated substances. In addition, except for suction piping that meets the requirements of R18-12-241(C)(2)(a) through (e), tanks and piping installed or replaced after January 1, 2009 shall be secondarily contained and use interstitial monitoring in accordance with R18-12-243(G). Secondary containment shall be able to contain regulated substances leaked from the primary containment until they are detected and removed and prevent the release of regulated substances to the environment at any time during the operational life of the UST system. For cases where the piping to be replaced exceeds the percentage in A.R.S. § 49-1009(C), the entire piping run shall be secondarily contained.

Tank ID #

ATG Model

ATG Probe Model

Model

Model

Model

Model

about release detection and IM sensors

FINAL INSPECTION SYSTEM TESTING INFORMATION

Complete the items directly related to the modifications.

Tank ID #

Test Date

Line Leak Detector Test Results

Testing Company Address

Testing Technician

ADEQ Testing Certification #

Technician’s Email

Primary Phone #

GENERAL COMMENTS about system testing

CLOSURE INSPECTION GENERAL COMMENTS

Service Provider’s Name

ADEQ Certification #

Service Provider’s Email

Primary Phone

Service Provider’s Signature

Date

Inspector’s Name

Inspector’s Email

Primary Phone

Inspector’s Signature

Date

PRE-BURIAL INSPECTION GENERAL COMMENTS

_______ I (the service provider) have personally verified that all UST system components installed for this inspection are compatible with the fuels that will be stored and are installed according to manufacturers’ instructions and the applicable installation standards and codes of practice in R18-12-220 and R18-12-281.

Concluded inspection. Debriefed service provider. Finalized report. Submitted report from site.

Service Provider’s Name

ADEQ Certification #

Service Provider’s Email

Primary Phone

Service Provider’s Signature

Date

Inspector’s Name

Inspector’s Email

Primary Phone

Inspector’s Signature

Date

FINAL INSPECTION GENERAL COMMENTS

_______ I (the service provider) have personally verified that all UST system components installed for this inspection are compatible with the fuels that will be stored and are installed according to manufacturers’ instructions and the applicable installation standards and codes of practice in R18-12-220 and R18-12-281.

Concluded inspection. Debriefed service provider. Finalized report. Submitted report from site.

Service Provider’s Name

ADEQ Certification #

Service Provider’s Email

Primary Phone

Service Provider’s Signature

Date

Inspector’s Name

Inspector’s Email

Primary Phone

Inspector’s Signature

Date

Modification Inspection, Page 15

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