Exhibit E - UST Interior Lining Inspection Report.docx
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- Attached to
- Master Agreement AZ|CTR067133
- Contract number
- CTR067133
- Issued by
- Arizona
About this file
This document is an Underground Storage Tank (UST) Interior Lining Inspection Report issued by the Arizona Department of Environmental Quality (ADEQ), located in Phoenix, Arizona. The form is a comprehensive inspection checklist designed to document the assessment, preparation, and post-installation review of underground storage tank interior lining services, with sections dedicated to facility, owner, and tank information, as well as detailed pre-entry, entry, and post-lining assessment protocols.
The inspection report covers multiple technical aspects of UST relining, including evaluations of tank condition, compatibility of lining materials with stored products, and compliance with state regulatory standards. Key components of the inspection include assessing tank damage types (such as fractures, punctures, and delamination), verifying resin compatibility, conducting tank tightness tests, and ensuring proper installation methods. The document requires detailed documentation from service providers, including manufacturer certifications, testing results, and confirmation of adherence to Arizona administrative codes R18-12-220 and R18-12-281, with follow-up documentation to be submitted to ADEQ's UST Plan Review division.
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Text version
BPM005267 Exhibit E
UST INTERIOR LINING INSPECTION REPORT
ARIZONA DEPARTMENT OF ENVIRONMENTAL QUALITY
1110 West Washington Street, Phoenix, Arizona 85007 ADEQ Help Line (In-State Only) 1-800-234-5677
| INSPECTION INFORMATION |
| ADEQ Plan Review # |
| MD |
Date of Pre-Entry Contact with Contractor
Entry/Pre-Lining Inspection to occur AFTER tank assessment but BEFORE lining begins.
Date of Entry / Pre-Lining Inspection
| Date of Pre-Burial Inspection |
| (Required if spill bucket, containment sump, or piping is disturbed.) |
Contractor to schedule Post-Entry Inspection to allow observation of tank / line / hydrostatic testing.
If on-site Post-Entry Inspection is not required, submit documentation of items listed in Post-Lining Assessment
FACILITY INFORMATION
Facility Name
ADEQ Facility ID
Facility Address
City & Zip
| Facility County |
| Choose an item. |
| OWNER INFORMATION |
UST Owner Name
Mailing Address
Owner Contact Name
Contact Title
Owner Contact Email
Contact Phone #
| Is F.R. current? |
| YES ☐ No ☐ |
| F.R. Expiration |
PERSON QUALIFIED TO DETERMINE WHETHER TANKS ARE SUITABLE FOR LINING/REPAIR
Company
Individual’s Name
Individual’s Title
Individual’s Email
Phone #
INTERIOR LINING SERVICE PROVIDER INFORMATION
Service Provider Company
Address of Service Provider Company
Service Provider Name
| ADEQ Certification # |
| IL00 |
Email Address
Phone #
Resin on Contractor’s License
| Manufacturers’ Certifications |
| Contractor to submit to Plan Review letter(s) from the manufacturers of the materials to be used in the relining process that 1) authorize the contractor’s use of the material, and 2) affirm the material’s compatibility with the product(s) stored in the USTs to be lined. |
TANK INFORMATION (each compartment is to be listed in a separate column)
Tank ID #
Installation Date
Tank Manufacturer
Tank Model
| Compartmentalized Tank | ||||
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
| Compartment Size |
| Tank Wall Type | ||||
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
| Tank Material Construction | ||||
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
| Tank Corrosion Protection | ||||
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
| Product | ||||
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
| Tank Status | ||||
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
| If in Temp Closure: |
Date placed in TC
Suspected Release #
LUST #
| Was tank lined previously? | ||||
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
| Date of Last |
Tank Tightness Test
Testing Company
| Result | ||||
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
| Comments |
SCOPE OF WORK
Tank ID #
| Intended Scope of Work | ||||
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
| Is reline allowed by tank manufacturer? | ||||
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
| USTs will be opened, relined, & returned to service | ||||
| All at the same time ☐ Individually / one at a time ☐ |
REASON for interior lining
| Method to be used to vapor-free UST | ||||
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
| Method of TANK ENTRY | ||||
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
| Has the PRODUCT PIPING been disturbed? | ||||
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
| RESIN to be used to re-line these tanks |
| Is the resin compatible with the product to be stored in the UST? | ||||
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
| Does the resin on-site match the resin intended to be used? | ||||
| Choose an item. | ||||
| Does the resin on-site match the resin on the contractor’s license? | ||||
| Choose an item. | ||||
| Is the resin UL listed? | ||||
| Choose an item. | ||||
| If the resin is NOT UL listed, is the material approved by the tank manufacturer? | ||||
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
| LINING MATERIAL |
| Is the lining material compatible with the product to be stored in the UST? | ||||
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
PRE-ENTRY INFORMATION PROVIDED BY SERVICE PROVIDER
Tank ID #
Date Fuel Removed
| Emptied to less than 1” | ||||
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
| Date of Triple Rinse |
Triple Rinse performed by
| All Electrical Equipment to Turbines and Ancillary Equipment is Disconnected | ||||
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
| (comment such as: LOTO at electrical panel / yoke disconnected) |
| (comment such as: LOTO at electrical panel / yoke disconnected) |
| (comment such as: LOTO at electrical panel / yoke disconnected) |
| (comment such as: LOTO at electrical panel / yoke disconnected) |
| (comment such as: LOTO at electrical panel / yoke disconnected) |
| Method used to vapor-free UST | ||||
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
ENTRY / PRE-LINING ASSESSMENT OF FRP USTs
Tank ID #
| Evaluation Method | ||||
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
| FTPI T-95-1 Tank Damage Classifications | ||||
| For any “Yes” answers, add narrative in the Comments Regarding Tank Damage section. |
| FRACTURES (cracking) |
| A crack in the FRP sometimes causing delamination. This is usually caused by a significant impact. Some tank sections may be torn out of the tank and may need rebuilding. (FTPI T-95-1) |
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
| PUNCTURES (holes) | ||||
| A hole or penetration in the surface of the fiberglass laminate. A sharp object may pierce the tank wall. A puncture is usually “clean” with little distortion to the area around the damage. (FTPI T-95-1) |
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
| DELAMINATION | ||||
| The rupture of internal bonding between layers of fiberglass and resin. A separation in the layers of Fiberglass, or a peeling away of secondary bond laminate. This type of damage occurs mostly at the fittings, lift lug or other tank attachments. However, it may also be seen at the ribs or the inside of a tank. (FTPI T-95-1) |
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
| MISSING SECTIONS | ||||
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
| SURFACE CRACKING | ||||
| These are generally small cracks that appear in the surface of the tank, inside or out. For the most part they do not penetrate the tank wall. These are minor in nature but need the same professional attention as the other types of damage. (FTPI T-95-1) |
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
| GEOMETRIC DISTORTION | ||||
| This is an out-of-round condition with unequal vertical and horizontal measurements or bottom flattening. Tank geometry changes are usually the result of improper installation methods, which can be detected by measuring the tank diameter after installation and before the tank is placed in service. (FTPI T-95-1) |
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
| LOCAL BUCKLING | ||||
| This is the distortion of the shell wall between the ribs. (FTPI T-95-1) |
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
| Is UST suitable for the intended scope of work per the qualified person? | ||||
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
| Comments |
ENTRY / PRE-LINING ASSESSMENT OF STEEL USTs
Tank ID #
Metal Thickness Reading
Testing Method(s)
| Is tank suitable for the intended scope of work per the qualified person? | ||||
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
| Comments |
POST-LINING ASSESSMENT OF USTs
| API 1631 Form B provided for each compartment | ||||
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
| Shell Thickness |
Method for determining shell thickness
Lining Hardness Reading
Method for determining hardness
PRE-BURIAL INSPECTION
Tank Tightness Test Date
| Tank Tightness Test Result | ||||
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
| Hydrostatic Test Date |
| Sumps Tested | ||||
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
| Hydrostatic Test Result | ||||
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
| Line Tightness Test Date |
| Line Tightness Test Result | ||||
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
| PRECISION TESTING |
Tank Tightness Test Date
| Tank Tightness Test Result | ||||
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
| Line Tightness Test Date |
| Line Tightness Test Result | ||||
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
| Testing Company |
Tester’s Name
Tester’s ADEQ #
| For steel USTs, is cathodic protection restored? | ||||
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
| Cathodic Protection Method | ||||
| Choose an item. | Choose an item. | Choose an item. | Choose an item. | Choose an item. |
GENERAL COMMENTS regarding INTERIOR LINING INSPECTION
Walked site with Service Provider. Conducted inspection.
_______ 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.
Follow-up action is needed: submit 3rd party tank testing documentation and documentation of items listed in Post Lining portion of checklist to USTPlanReview@azdeq.gov.
Inspector’s Printed Name
Inspector’s Signature
Date
Service Provider’s Name
Service Provider’s Signature
Date
GENERAL COMMENTS regarding PRE-BURIAL INSPECTION
Walked site with Service Provider. Conducted inspection.
_______ 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.
Follow-up action is needed: submit 3rd party tank testing documentation and documentation of items listed in Post Lining portion of checklist to USTPlanReview@azdeq.gov.
Inspector’s Printed Name
Inspector’s Signature
Date
Service Provider Company
Service Provider Name
| ADEQ Certification # |
| INR0 |
Email Address
Phone #
Service Provider’s Signature
Date
Interior Lining Inspection Report - Page 6
PHOTO LOG
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