Exhibit D - UST INSTALLATION INSPECTION REPORT.docx

BPM005267 Exhibit D

UST INSTALLATION INSPECTION REPORT

ARIZONA DEPARTMENT OF ENVIRONMENTAL QUALITY

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

Pre-Burial Tank Date

Arrival Time

Departure Time

Pre-Burial Piping Date

Arrival

Departure Time

Final Inspection 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 #

INSTALLER INFORMATION

Service Provider Company

Service Provider Address

Primary Contact

Position

Email Address

Primary Phone #

INSTALLATION INFORMATION

Bedding Depth

Top of Tank Depth

Bottom of Tank Depth

Well Location(s)

TANK INSTALLATION INFORMATION

Complete One Column for Each Compartment

Tank ID #

Tank Gallon Capacity

for JET FUELS, identify the type of Jet Fuel (Jet A, Jet A-1, Jet B, JP-4, JP-5, JP-8, etc). For NEW OIL, provide SMS data sheet.

Product Subquestion

TANK MANUFACTURER

Tank Model

Tank Diameter

Tank Length

UL#

Serial #

Vacuum Gauge Reading after 1-hour wait period (if applicable)

Pressure Test Result (PSI)

Soap Bubble Test Date

TANK INSTALLATION INFORMATION - continued

Tank ID #

(UST on bedding material)

Vertical measurement after anchoring UST

Vertical measurement after backfilling to tank top

Space from USTs to basin walls

GENERAL COMMENTS about UST installation

ANCILLARY EQUIPMENT INFORMATION

Tank ID #

Manufacturer & Model

type of gauge

Size (Gallons)

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

Spill Containment Integrity Test Date

POST-test Height

Fill Adapter Manufacturer & Model

Model #

Activation Level

Model #

Activation Level

VAPOR RECOVERY CAP Manufacturer & Model

Vapor Recovery Adapter Manufacturer & Model

GENERAL COMMENTS about Spill Containment

ANCILLARY EQUIPMENT INFORMATION

Tank ID #

STP Containment Model

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

STP Containment Hydrostatic Test Date

POST-test Height

Quantity of STPs

STP Turbine Manufacturer

STP Turbine Model(s)

STP Turbine Serial #

Line Leak Detector Model

Line Leak Detector Serial #

PIPING INFORMATION

Tank ID #

Piping Model 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

DISPENSER INFORMATION

Dispenser Manufacturer (if available)

Dispenser Model (if available)

UDC Sump Model

Piping Connector Mfgr

Piping Connector Model

GENERAL COMMENTS about Dispensers

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

SHEAR VALVE INFORMATION

Shear Valve Model

Number of Shear Valves per product

Dispenser(s) where shear valves were checked

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 Serial Number

If using existing ATG console, list console upgrades

TANK IM SENSOR Model

ATG Probe Serial Number

Model

Quantity

Model

Quantity

Model

Quantity

Model

Quantity

FINAL INSPECTION SYSTEM TESTING INFORMATION

Tank ID #

Test Date

Line Leak Detector Test Results

Items Tested

Testing Company Address

Testing Technician

ADEQ Testing Certification #

Technician’s Email

Primary Phone #

TESTING COMPANY

Items Tested

Testing Company Address

Testing Technician

ADEQ Testing Certification #

Technician’s Email

Primary Phone #

GENERAL COMMENTS about system testing

OWNER / OPERATOR REPRESENTATIVE

During the final inspection, the Inspector explained the UST system, testing, and release detection requirements to the Owner/Operator’s representative.

Owner Contact Name

Contact Title

Owner Contact Email

Contact Phone #

Signature

Date

GENERAL COMMENTS

about release detection and IM sensors

PRE-BURIAL TANK 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.

Concluded inspection. Debriefed service provider. Departed site at am. Finalized and submitted report from office on /2022.

Service Provider’s Name

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 PIPING 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. Departed site at am. Finalized and submitted report from office on /2022.

REMINDER TO SYSTEM OWNERS/OPERATORS: a completed notification form must be submitted to ADEQ through myDEQ after the Final Installation Inspection has been completed, submitted, and processed by ADEQ.

Service Provider’s Name

Service Provider’s Email

Primary Phone

Service Provider’s Signature

Date

Inspector’s Name

Inspector’s Email

Primary Phone

Inspector’s Signature

Date

FINAL INSTALLATION 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. Departed site at am. Finalized and submitted report from office on /2022.

REMINDER TO SYSTEM OWNERS/OPERATORS: a completed notification form must be submitted to ADEQ through myDEQ after the Final Installation Inspection has been completed, submitted, and processed by ADEQ.

Service Provider’s Name

Service Provider’s Email

Primary Phone

Service Provider’s Signature

Date

Inspector’s Name

Inspector’s Email

Primary Phone

Inspector’s Signature

Date

NT , page 1

PHOTO LOG FOR INSTALLATION OF TANKS ON

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