P04 VA Inspection Checklist Template.pdf

DEPARTMENT OF VETERANS AFFAIRS

Health Care Systems

2101 N Elm Street

Fargo, ND 58102-2498

Aboveground and Underground Petroleum Storage

INSPECTION AND SCHEDULED MAINTENANCE CHECKLIST

Date ______________________________________________

Name of Company ___________________________________________________________

Technician Name ____________________________________________________________

Annual Triannual

Fuel Tank Number __________________________ Aboveground Underground

Tank Location _________________________________________________________________________

Contents #2 Diesel #1 Diesel

Capacity (gallons) 75 100 150 200 4,000 20,000

Construction Double-walled steel Other __________________________________

Container Steel Other ________________________________________

Please see next page for checklist

Annual Testing – minimum testing

TANK AND PIPING

1. Is tank exterior (roof, shell, heads, bottom, connections, fittings, valves, etc..)

free of visible leaks? Yes No

2. Are there any trip hazards with the tank pad or pavement? Yes No

3. Is the Vent Piping secured properly? Yes No

4. Is the containment area free of excess liquid, debris, cracks, corrosion, erosion, fire hazards and other integrity issues? Yes No

5. Are piping connections to the tank free of visible leaks?

Yes No

TANK SUBMERSIBLE PUMP INSPECTIONS

1. Are junction boxes sealed, free of corrosion, seal-offs present, intrinsically safe wiring in good condition? Yes No

2. Are the flexible connectors in good condition? Yes No

3. Are the piping connections to the STP in good condition? Yes No

UST SUMP INSPECTION

1. Inspection for water or product completed?

Inspection satisfactory? Yes No

2. Inspection of Sumps for cracks, penetration, or bulges Inspection satisfactory? Yes No

3. Penetration fittings inspected Inspection satisfactory? Yes No

4. Inspection of Sump sensor and Sensor Test completed Inspection satisfactory? Yes No

5. Inspection of Sump cover, gaskets and seals completed Inspection satisfactory? Yes No

6. Manway Inspection completed Inspection satisfactory? Yes No

DISPENSER INSPECTIONS

1. Inspection of dispenser leaks Inspection satisfactory? Yes No

2. Inspection of Electrical Junction boxes Inspection satisfactory? Yes No

3. Inspection of Safety Shear Valve Inspection satisfactory? Yes No

4. Inspection of Safety Shear Valve Mounting Inspection satisfactory? Yes No

5. Inspection of Dispenser Piping Inspection satisfactory? Yes No

ATG MANHOLE INSPECTIONS

1. Inspection of ATG Probe riser pipe Cap and Adaptor Inspection satisfactory? Yes No

2. Inspection of Electrical Junction Box Inspection satisfactory? Yes No

3. Inspection of ATG Manhole

Inspection satisfactory? Yes No

4. Inspection of ATG Manhole Inspection and cleaning complete? Yes No

SPILL/FILL MANHOLE INSPECTION

1. Inspection Overfill Valve and Drop Tube Inspection satisfactory? Yes No

2. Clean/Remove any buildup of sand, gravel, or dirt from the containment bucket and manhole top cast flange. Yes No

3. Inspection of containment bucket for cracks, penetrations, or other damage Inspection satisfactory? Yes No

ATG CONSOLE SYSTEM INSPECTION

System Status

Inspect Console has no active warnings or alarms Inspection satisfactory? Yes No

The Alarm history shows no recurring leak alarms Inspection satisfactory? Yes No

Verify in-tank leak detection tests are being completed Yes No

Verify piping leak detection tests are being completed Yes No

Programming Inspection

Verify correct set-up parameters for the in-tank test Yes No

Verify correct set-up parameters for electronic line leak detector Yes No

Triannual Testing – minimum testing

Spill bucket Sump Integrity Test Test satisfactory? Yes No

Overfill Prevention Equipment Functionality Test Test satisfactory? Yes No

Tank Cathodic Protection Test Test satisfactory? Yes No

Pipeline Cathodic Protection Test Test satisfactory? Yes No

Note: If “No”, identify any issue and action taken.