P09. Removal Replacement of Exist 10k 30k USTs SOW Attachments ONLY.pdf

GOVERNMENT OF THE DISTRICT OF COLUMBIA

Department of Energy and Environment Environmental Services Administration

Underground Storage Tank Branch * * * Toxic Substance Division

VETERANS ADMIN MEDICAL CENTER

50 IRVING STREET, NW

C/O Timothy M Williams Environmental Compliance Officer

Washington, DC 20422

Dear Tank Owner/Operator, 01/11/2023

The District of Columbia's Department of Energy and Environment (DOEE) wishes to inform you, as the owner or operator of one or more underground storage tanks in the District, of a UST that is more than thirty (30) years old shall remove the tank from the ground in accordance with Chapter 57 within five (5) years of February 21, 2020. See

20 DCMR § 5700.10 and 5700.11 below:

5700.10 Each owner or operator of a UST that is more than thirty (30) years old shall remove the tank from the ground in accordance with Chapter 61 within five (5) years of February 21, 2020.

5700.11 Each owner or operator of a UST that is more than thirty (30) years old shall perform a tightness test within one (I) year of February 21, 2020, and if the UST fails, remove the UST within one (1) year of the date of the test failure.

If you are receiving this letter our records indicate that you are an owner of an aged tank (30 years or older), or about to an owner of an aged tank that is required to meet this requirement by the year 2025. The facilities included have tanks with an install date of 1994 or greater that are currently in use or temporarily closed. The following tank(s) have met the criteria to meet the aged tank requirement by February 21, 2025:

Address

50 IRVING ST NW

50 IRVING ST NW

Tank# Installed

6 3/1/1992

7 7/1/1994

Capacity Substance

10000 Diesel

30000 Diesel

To meet this requirement, you must perform a Tank Tightness Test or have performed a Tank Tightness Test in the last 12 months. Submit your Tank Tightness Test results within 30 days of this letter to the Underground Storage Tank Program, attention Sharon Hamilton. If any of the information we have is incorrect or was changed recently, e.g.

ownership, tank age, or description, please submit it. Should you fail to comply with this directive DOEE will pursue enforcement action, including a penalty and fine.

Thank you for your cooperation and compliance with this directive. We look forward to working with you to meet this 2025 compliance requirement. Should you have any questions, you may contact Ms. Sharon Hamilton, Environmental Specialist, at (202) 535-1950 or sharon.hamilton@dc.gov. Visit our website https://doee.dc.gov/service/underground-storage-tank-program to access updated UST regulations, staff contact details, and other information and updates.

Sincerely, Fianna Phill, Chief Underground Storage Tank Branch

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Waitzman, Deborah R.

From: Hamilton, Sharon (DOEE) <sharon.hamilton@dc.gov> Sent: Tuesday, March 14, 2023 2:45 PM To: Williams, Timothy M.

Cc: Staton, Stanley (WAS); Carswell, Vicky; Wilson, McClenton J., (WAS); Warren, Cynthia R.; Gough, Ramon A.; Maistros, Angela; Lucas, Gregory J.; Greene, Jerry; Faye, Elhadji; Pejo, Arben Subject: [EXTERNAL] Re: DC VA Medical Center's 2022 Tank Tightness Tests for DOEE UST Branch 30 Year

Notification

Good Afternoon Mr. Williams, Thank you for submitting your results in a timely manner. I will update your records.

Sharon Hamilton Environmental Protection Specialist Department of Energy and the Environment Underground Storage Tank Program 1200 First Street, NE 5th Floor Washington, DC 20002 Office: 202 535 1950 Cell: 202 878 0326 Fax: 202 535 1383 Email: Sharon.Hamilton@DC.GOV Web: DOEE.DC.GOV Telework: Tuesday and Thursday

COVID 19 Notice to stakeholders:

https://doee.dc.gov/sites/default/files/dc/sites/ddoe/release_content/attachments/3.31.20_DOEE%20FINAL%20USTB% 20Public%20Notice signed.pdf <https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fdoee.dc.gov%2Fsites%2Fdefault%2Ffiles%2Fdc %2Fsites%2Fddoe%2Frelease_content%2Fattachments%2F3.31.20_DOEE%2520FINAL%2520USTB%2520Public%2520No tice signed.pdf&data=05%7C01%7C%7C774948f086724f8d1a2908db24bc3894%7Ce95f1b23abaf45ee821db7ab251ab3bf%7 C0%7C0%7C638144163388399388%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik 1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=J0lDzGey%2BQA968ljWRBF%2Fvx9EwOKZ2%2B9UuN27eGw9q E%3D&reserved=0>

(Link to UST Branch website):

https://doee.dc.gov/service/underground storage tank program <https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fdoee.dc.gov%2Fservice%2Funderground storage tank program&data=05%7C01%7C%7C774948f086724f8d1a2908db24bc3894%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C 0%7C0%7C638144163388399388%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1

(DOEE)

ATTACHMENT 2

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From: Williams, Timothy M. <Timothy.Williams@va.gov> Sent: Tuesday, March 14, 2023 2:35 PM To: Hamilton, Sharon (DOEE) <sharon.hamilton@dc.gov> Cc: Staton, Stanley (WAS) <Stanley.Staton@va.gov>; Carswell, Vicky <Vicky.Carswell@va.gov>; Wilson, McClenton J., (WAS) <McClenton.Wilson@va.gov>; Warren, Cynthia R. <Cynthia.Warren4@va.gov>; Gough, Ramon A.

<Ramon.Gough@va.gov>; Maistros, Angela <Angela.Maistros@va.gov>; Lucas, Gregory J. <Gregory.Lucas1@va.gov>;

Greene, Jerry <Jerry.Greene@va.gov>; Faye, Elhadji <Elhadji.Faye@va.gov>; Pejo, Arben <Arben.Pejo@va.gov> Subject: DC VA Medical Center's 2022 Tank Tightness Tests for DOEE UST Branch 30 Year Notification

CAUTION: This email originated from outside of the DC Government. Do not click on links or open attachments unless you recognize the sender and know that the content is safe. If you believe that this email is suspicious, please forward to phishing@dc.gov for additional analysis by OCTO Security Operations Center (SOC).

Facility No. 4000719

Good afternoon Ms. Hamilton, Per our last phone conversation about the notification (attached) sent to the facility by the UST Branch regarding our 10,000 and 30,000 gallon underground storage tanks (both over 30 years old), I have attached copies of the tank tightness tests conducted on each of the USTs on March 6th. Both tanks passed, and the result of the tightness tests can be seen on page 2 of each report. The reports comply with the requirements of the notification for the medical center to provide evidence that the tank tightness tests were conducted on our USTs within the last 12 months.

Also key internal stakeholders have been made initially aware of the primary requirement discussed in the notification and underground storage tank regulations in Title 20 DCMR that mandate both of the 30 + year old tanks be removed:

Chapter 5700, Section 11: “…Each owner or operator of a UST that is more than thirty (30) years old shall remove the tank from the ground in accordance with Chapter 61 within five (5) years of February 21, 2020…”

Consequently, specific stakeholders such as our project engineers have been made aware of the short time line the facility will have to meet to ensure it complies with removal of the tanks before the deadline of February 21, 2025. They

Facility No. 4000719

10,000 and 30,000 gallon underground storage tanks (both over 30 years old), I have attached copies of the tank tightness tests conducted on each of the USTs on March 6th. B have already begun the coordination of getting this endeavor identified as a construction project and getting agency funding for it. Near the start date of the removal project, the facility will submit DOEE’s UST Activity Notification Form to the UST Branch at least 5 days prior to the scheduled date of construction. The medical center will also call the UST Branch at least 24 hours prior to the scheduled date of activity to make an appointment for a DOEE inspector to be present during the tank activity, so he/ she/ they can perform an inspection immediately following the completion of the project for enforcement purposes.

If there is any other additional information you need at this time in regards to our future project plans please let us know.

Regards, Timothy M. Williams

Green Environmental Management System (GEMS) Manager

Washington, D.C. VA Medical Center

50 Irving St. NW, Washington, D.C. 20422

Office: (202) 745 8000, ext. 58702

Cell: (202) 215 4723 timothy.williams@va.gov <mailto:timothy.williams@va.gov>

MONTHLY/ANNUAL UST SYSTEM INSPECTION CHECKLIST - only heating oil USTs under 1,100 gallons are exempt

Facility ID# Facility Name Facility Address Inspector/Operator Date

Signature: Correct & Report evidence of a release/product or damaged/broken spill bucket, equipment, failures to DC

Description

PEI/RP900 Tank1 Tank 2 Tank 3 Tank 4 Tank 5

Category 7.4 g7.5.1

Release Detection Recordkeeping

Circle method of tank leak detection: ATG, CIM, SIR, IC, GWM, SVM, MIMT Circle method of piping leak detection: CIM, MPLT, SIR, GWM, SVM, MIMP 7.6

Automatic Tank Gauge (ATG) On, working, no alarms,test report printed & filed 7.6.1.1 Continuous Interstitial Monitoring

(CIM) Sensor status report printed and properly filed 7.6.2.1

Monthly Piping Leak Test (MPLT) Piping leak test report printed/documented and properly filed 7.6.3.1 Statistical Inventory

Reconciliation (SIR) Last month’s SIR results passed and available for inspection 7.6.4.1

Inventory Control (IC) Inventory reconciled and within the company or regulatory standard 7.6.5.1 Manual Groundwater Monitoring

(GWM) Groundwater bailer in good condition 7.6.6.1

Manual Groundwater (GWM) or Soil Vapor Monitoring (SVM) Wells sampled and results pass 7.6.6.2

Manual Interstitial Monitoring for Tanks (MIMT)

Steel tank: interstitial space checked and found dry 7.6.7.1

Fiberglass tank: interstitial space checked and found dry 7.6.7.2

Fiberglass tank: level of monitoring fluid within normal range 7.6.7.3 For steel and fiberglass tanks, vacuum level is within tolerances 7.6.7.4 Tnk 1 vac: Tnk 2 vac: Tnk 3 vac: Tnk 4 vac:

Manual Interstitial Monitoring for Piping (MIMP)

Containment Sump (STP and/or remote fill sump) inspected and no liquid or debris found and senors in correct position. 7.6.8.1

All Tanks 7.7

7.7.1 Spill Kit All components of the spill kit are present and in good condition

Grade-Level Covers All covers present, in good condition,seated firmly on correct tank, color coded 7.7.2.1

Spill Containment Manhole Drain valve in spill containment manhole in good condition 7.7.3.1

Interstitial space of double-walled containment manhole is dry, free of debris 7.7.3.2

D.C. DOEE MONTHLY WALK THROUGH UNDERGROUND STORAGE TANK SYSTEM INSPECTION FORM

Adopted from www.pei.org/RP900-Appendix A2, 2017. In accordance with 20 DCMR 5904 DOEE V-1-09.21.21

DOEE - 202-535-2600

Take action of any unusual conditions, e.g. alarms, damage, leaks and note corrective actions on next page.

Email: ust.doee.dc.gov

USTs receiving deliveries >30 days intervals, may check their spill buckets prior to each delivery.

Visit: https://doee.dc.gov/service/underground-storage-tank-program OR DOEE-UST Branch, 1200 1ST NE, 5th Fl. Washington DC 20002 OR e-mail:ust.doee@dc.gov

ATTACHMENT 3a fianna.phill Highlight fianna.phill Highlight fianna.phill Highlight fianna.phill Highlight fianna.phill Highlight fianna.phill Highlight

Category Description PEI/RP900 N/A Tank 1 Tank 2 Tank 3 Tank 4

Drop Tube Drop tube present, smooth, no ragged edges, in good condition, no obstruction7.7.4.1 Top edge of coaxial drop tube smooth, round, slightly below the top edge 7.7.4.2 of the fill pipe Hand Held Devices & Tank Gauge Stick Tank gauge stick can be clearly read, is not warped or broken,tip present 7.7.5.1

Check for Water No water present in the tank 7.7.6.1

Tank Vents Vent cap present, vent pipe solidly supported and vertical 7.7.7.1

Stage I Vapor Recovery 7.8

Two-Point (Dual-Point) Vapor Recovery

7.8.1.1 Cover present, colored orange, seated firmly at grade, not broken, cracked or chipped If spill containment manhole is present, no debris, water or product 7.8.1.2

If spill containment manhole is present, no cracks, bulges or holes 7.8.1.3

Vapor recovery cap and poppet of adaptor in good condition, seals tightly 7.8.1.4

Flex connectors has no signs of damage, leaks 7.8.1.5

Observation and Monitoring Wells 7.9

Observation well cover is properly identified and secured 7.9.1.1

Corrosion Protection 7.10

Impressed-Current Cathodic Protection

Record Volt, Amp/Hours readings, check consistency with previous months 7.10.1.1 Check Rectifier if powered on, for normal operation and record green light indicator (if equipped) 7.10.1.2

Dispensers and Submersible Turbine Pumps (STPs) 7.11

Components are clean & dry, no damage or signs of cracks of homes 7.11.1

7.11.2 Shear valve correctly anchored & sensors in correct positions

DESCRIBE ANY DEFICIENCIES & CORRECTIVE ACTIONSTAKEN HERE OR USE EXTRA PAGE:

Instructions: Mark each tank where no problem is observed with a checkmark: √ If certain equipment is not required and / or not present, mark checklist in the N/A column. If a defect is found, mark the checklist with an “X,” describe the problem in the “DEFICIENCIES” section, and notify the appropriate person. Refer to the section listed in the “PEI/RP900” column for additional information.

Refer to PEI RP500, Recommended Practices for Inspection and Maintenance of Motor Fuel Dispensing Equipment, for inspection procedures that apply to fuel dispensing equipment.

UST Owners & Operators are required to maintain a copy of this record for 10 years, including delivery records if spill prevention equipment are not checked every 30 days.

Functionality tests of the LLD, Sumps/spill buckets, and overfill and testing equipment should be completed as is required, records kepts and failures reported to DOEE .

D.C. DOEE MONTHLY WALK THROUGH UNDERGROUND STORAGE TANK SYSTEM INSPECTION FORM Adopted from www.pei.org/RP900-Appendix A2, 2017. In accordance with 20 DCMR 5904 DOEE V-1-09.21.21 – Page 2

Visit: https://doee.dc.gov/service/underground-storage-tank-program OR DOEE-UST Branch, 1200 1ST NE, 5th Fl. Washington DC 20002 OR e-mail:ust.doee@dc.gov

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Form Version 1, September, 2021

GOVERNMENT OF THE DISTRICT OF COLUMBIA

DEPARTMENT OF ENERGY AND ENVIRONMENT

UNDERGROUND STORAGE TANKS BRANCH

1200 FIRST STREET, NE, 5TH FLOOR, Washington, D.C. 20002-3315

Phone: (202) 535-2600 FAX: (202) 535-1383 Website: http://doee.dc.gov, Email: UST.DOEE@dc.gov

UNDERGROUND STORAGE TANK

SPILL PREVENTION EQUIPMENT/CONTAINMENT SUMP INTEGRITY TESTING FORM

I. FACILITY INFORMATION – Type or print (in ink) all items.

Facility ID #: Facility Name:

Facility Street Address:

Facility Telephone: Facility Email: Ward:

II. TESTER INFORMATION

Tester Name: Tester Cert. #: Tester Telephone:

Company Name: Company Cert. #: Test Date:

III. TEST METHOD

Method Used Hydrostatic1 Vacuum Pressure

Other

Method Developer Manufacturer Industry Standard Other

IV. VISUAL INSPECTION INFORMATION

Tank Number

Product Stored

Containment Number2

Containment Type Dispenser

Tank Top Sump

Fill Spill Bucket

Transition

Dispenser

Tank Top Sump

Fill Spill Bucket

Transition

Dispenser

Tank Top Sump

Fill Spill Bucket

Transition

Dispenser

Tank Top Sump

Fill Spill Bucket

Transition

Dispenser

Tank Top Sump

Fill Spill Bucket

Transition

Containment Capacity

Manufacturer

Model3

Were There Visible Cracks, Holes or Other Failures in the Containment?

Yes No Yes No Yes No Yes No Yes No

Was There Product in the Containment Prior to Testing?

Yes No Yes No Yes No Yes No Yes No

Was Product and Debris Removed from the Containment Prior to Testing?

Yes

No

N/A

Yes

No

N/A

Yes

No

N/A

Yes

No

N/A

Yes

No

N/A

V. VISUAL RESULT4 Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail

ATTACHMENT 3b http://doee.dc.gov/

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1. For hydrostatic testing, attach documentation of proper disposal of the test fluids to this form. Describe level measurement methods in Section IX.

Comments.

2. Designate each device tested, numerically or by code, on the site drawing in Section X.

3. If model cannot be determined, describe device construction (Single-walled/Double-walled, Fiberglass, HDPE, etc.)

4. Failed visual inspections may constitute a suspected release. Certified individuals must report confirmed or suspected contamination to the Department within 24 hours of observing it. Facility owners/operators must investigate suspected releases within 7 days. Do not conduct additional testing if the device fails visual inspection.

Facility ID #: Facility Name: Test Date:

VI. TESTING INFORMATION

Tank Number

Product Stored

Containment Number5

Portion Tested6

Test Start Time

Test Start Level

Test End Time

Test End Level

Test Period

Level Change

Pass/Fail Threshold

VII. TEST RESULT7 Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail

5. Designate each device tested, numerically or by code, on the site drawing in Section X.

6. If the entire depth of the device was not tested, specify how much was tested. The start level for hydrostatic testing must be within 1.5” of the top of a spill bucket and at least 4” above the highest penetration in a containment sump.

7. Failed test results may constitute a suspected release. Certified individuals must report confirmed or suspected contamination to the Department within

24 hours of observing it. Facility owners/operators must investigate suspected releases within 7 days.

VIII. FAILURE DESCRIPTION

If any device fails visual inspection or testing, describe the reason for the failure and the location of the failure for each failed device (i.e. “Cracked entry boot 4” from the bottom of dispenser sump #A1” or “Hole in bottom of Tank 002 fill spill bucket”)

- 3 of 3 -

Facility ID #: Facility Name: Test Date:

IX. COMMENTS

The comments section should be used to note additional information discovered or actions taken during integrity testing that affect compliance at the facility. For example, include comments concerning any observations made by the tester that would affect the test results.

Include actions taken to repair or replace failed devices. Repairs to containment sumps and spill buckets require the use of a Department certified individual.

Attach documentation/manifest of proper disposal of hydrostatic test fluids at an offsite treatment/disposal facility, not to be reused on other DC sites.

If additional comment sheets are needed, label each sheet with the report header information and attach the sheet(s) to this form.

HYDROSTATIC TEST LEVEL MEASUREMENT

If devices were tested using a hydrostatic test, describe how level measurements were taken (i.e. from the bottom up, from the top down, from a mark on the sump wall)

X. SITE DRAWING

Provide a detailed site drawing of the applicable UST(s), product piping, fill lines, and containment device layout in the space below (or attach a detailed site drawing prepared on a separate sheet). In addition, clearly indicate which devices were tested. Label each device tested with a unique number or code, used in Sections IV and VI, above. Any other pertinent information should also be included.

VII. OWNER’S REPRESENTATIVE CERTIFICATION

I have reviewed this report. I certify under penalty of law that the information provided by me is true, accurate, and complete to the best of my knowledge and belief. Pursuant to D.C. Official Code § 22-2405, the making of a false statement in writing to any instrumentality of the District of Columbia government is a criminal offense punishable by criminal penalties.

Signature: Date Signed:

VIII. TESTER CERTIFICATION

By signing this document as the Tester, I certify under penalty of law that the information provided by me is true, accurate, and complete to the best of my knowledge and belief. Pursuant to D.C. Official Code § 22-2405, the making of a false statement in writing to any instrumentality of the District of Columbia government is a criminal offense punishable by criminal penalties.

Tester’s Signature: Date Signed:

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Form Version 1, September 2021

GOVERNMENT OF THE DISTRICT OF COLUMBIA

DEPARTMENT OF ENERGY AND ENVIRONMENT

UNDERGROUND STORAGE TANKS BRANCH

1200 FIRST STREET, NE, 5TH FLOOR, Washington, D.C. 20002-3315

Phone: (202) 535-2600 FAX: (202) 535-1383 Website: http://doee.dc.gov, Email: UST.DOEE@dc.gov

UNDERGROUND STORAGE TANK

GROUNDWATER/VAPOR MONITORING SYSTEM FUNCTIONALITY TESTING FORM

I. FACILITY INFORMATION – Type or print (in ink) all items.

Facility ID #: Facility Name:

Facility Street Address:

Facility Telephone: Facility Email: Ward:

II. TESTER INFORMATION

Tester Name: Tester Cert. #: Tester Telephone:

Company Name: Company Cert. #: Test Date:

III. TEST PROCEDURE – Briefly describe procedure(s) used to evaluate/test the groundwater or vapor monitoring system.

IV. GROUNDWATER/VAPOR MONITORING SYSTEM TESTING INFORMATION

Tank Number

Product Stored

Site evaluated by a licensed professional to establish the number and positioning of monitoring wells that will detect releases within the excavation zone from any portion of the tank that routinely contains product. Yes No

Written site evaluation readily available at the facility: Yes No Date of site evaluation:

Name of licensed professional: License number:

Wells are installed in accordance with the site evaluation: Yes No

A. GROUNDWATER MONITORING

Product detection devices can detect 1/8-inch or less of leaked product on top of the groundwater:

Yes No

Electronic sampling equipment tested and operating properly: Yes No N/A

Date sampling equipment was last calibrated:

B. VAPOR MONITORING

Monitoring devices are capable of detecting increases in concentrations of stored regulated substances:

Yes No

Electronic sampling equipment tested and operating properly: Yes No

Date sampling equipment was last calibrated:

V. TEST RESULT Pass Fail

Any “No” answer in Section IV. Indicates the Groundwater or Vapor monitoring system fails. Failure of a release detection method may constitute a suspected release. Certified Individuals must report confirmed or suspected contamination to the Department within 48 hours of observing it. Facility owners/operators must investigate suspected releases within 7 days. If a reportable release is confirmed, it must be reported to the Department by telephone within 24 hours and requires immediate repair or replacement.

ATTACHMENT 3c

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VI. COMMENTS

The comments section should be used to note additional information discovered or actions taken during testing that affect compliance at the facility. For example, include comments concerning any observations made by the tester that would affect the test results.

Include actions taken to repair or replace failed devices.

If additional comment sheets are needed, label each sheet with the report header information and attach the sheet(s) to the back of this form.

VII. SITE DRAWING

Provide a detailed site drawing of the applicable UST(s), product piping, and monitoring well locations (or attach a detailed site drawing prepared on a separate sheet). Any other pertinent information should also be included.

VII. OWNER’S REPRESENTATIVE CERTIFICATION

I have reviewed this report. I certify under penalty of law that the information provided by me is true, accurate, and complete to the best of my knowledge and belief. Pursuant to D.C. Official Code § 22-2405, the making of a false statement in writing to any instrumentality of the District of Columbia government is a criminal offense punishable by criminal penalties.

Signature: Date Signed:

VIII. TESTER CERTIFICATION

By signing this document as the Tester, I certify under penalty of law that the information provided by me is true, accurate, and complete to the best of my knowledge and belief. Pursuant to D.C. Official Code § 22-2405, the making of a false statement in writing to any instrumentality of the District of Columbia government is a criminal offense punishable by criminal penalties.

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GOVERNMENT OF THE DISTRICT OF COLUMBIA

DEPARTMENT OF ENERGY AND ENVIRONMENT

UNDERGROUND STORAGE TANKS BRANCH

1200 FIRST STREET, NE, 5TH FLOOR, Washington, D.C. 20002-3315 Phone: (202) 535-2600 FAX: (202) 535-1383

Website: http://doee.dc.gov, Email: UST.DOEE@dc.gov

UNDERGROUND STORAGE TANK

OVERFILL PREVENTION EVALUATION FORM

I. FACILITY INFORMATION – Type or print (in ink) all items.

Facility ID #: Facility Name:

Facility Street Address:

Facility Telephone: Facility Email: Ward:

II. TESTER INFORMATION

Tester Name: Tester Cert. #: Tester Telephone:

Company Name: Company Cert. #: Test Date:

III. TANK AND DEVICE INFORMATION

Tank Number

Tank Capacity

Tank Diameter

Product Stored

Overfill Manufacturer

Overfill Model

Product Delivery Method

Pressurized

Gravity

Pressurized

Gravity

Pressurized

Gravity

Pressurized

Gravity

Pressurized

Gravity

Overfill Type

Drop Tube Shutoff

Alarm

Ball Float

Other

None

Drop Tube Shutoff

Alarm

Ball Float

Other

None

Drop Tube Shutoff

Alarm

Ball Float

Other

None

Drop Tube Shutoff

Alarm

Ball Float

Other

None

Drop Tube Shutoff

Alarm

Ball Float

Other

None

IV. TEST INFORMATION (Complete all applicable overfill types)

A. DROP TUBE SHUTOFF DEVICE

Drop tube and float free of debris?

Yes No Yes No Yes No Yes No Yes No

Float and poppet move freely?

Yes No Yes No Yes No Yes No Yes No

Poppet enters flow path when float is engaged?

Yes No Yes No Yes No Yes No Yes No

Tank capacity when flow is stopped (%)

B. OVERFILL ALARM

Visible and audible to delivery driver?

Yes No Yes No Yes No Yes No Yes No

Probe and float in good condition?

Yes No Yes No Yes No Yes No Yes No

Float moves freely? Yes No Yes No Yes No Yes No Yes No

Does simulated overfill trigger alarm?

Yes No Yes No Yes No Yes No Yes No

Tank capacity when alarm is triggered (%)

ATTACHMENT 3d

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C. BALL FLOAT VALVE

Standard drop tube installed?

Yes No Yes No Yes No Yes No Yes No

Is the only fill present a direct fill? Yes No Yes No Yes No Yes No Yes No

Ball and cage present and in good condition?

Yes No Yes No Yes No Yes No Yes No

Ball moves freely in cage?

Yes No Yes No Yes No Yes No Yes No

Tank capacity when flow is restricted (%)

D. OTHER, E.G. WHISTLE VENT

ALARM

Permanently Installed?

Yes No Yes No Yes No Yes No Yes No

Audible to delivery driver?

Yes No Yes No Yes No Yes No Yes No

Tank capacity when whistle stops (%)

OTHER

COMMENTS

V. TEST RESULTS Any “No” answer in Section IV. Indicates the overfill device fails. Failure of any overfill prevention device requires immediate repair or replacement. Underground Storage Tanks may not receive product deliveries without functional overfill prevention.

Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail

VI. COMMENTS

The comments section should be used to note additional information discovered or actions taken during functionality testing that affect compliance at the facility. For example, include comments concerning any observations made by the tester that would affect the test results.

Include actions taken to repair or replace failed devices. Installation, repair, and removal of overfill prevention devices requires the use of a Department certified individual. Failed ball float valves may not be repaired or replaced; an alternate form of overfill prevention must be installed.

If additional comment sheets are needed, label each sheet with the report header information and attach the sheet(s) to the back of this form.

VII. OWNER’S REPRESENTATIVE CERTIFICATION

I have reviewed this report. I certify under penalty of law as provided in that the information provided by me is true, accurate, and complete to the best of my knowledge and belief. Pursuant to D.C. Official Code § 22-2405, the making of a false statement in writing to any instrumentality of the District of Columbia government is a criminal offense punishable by criminal penalties.

Signature: Date Signed:

VIII. TESTER CERTIFICATION

By signing this document as the Tester, I certify under penalty of law as provided in that the information provided by me is true, accurate, and complete to the best of my knowledge and belief. Pursuant to D.C. Official Code § 22-2405, the making of a false statement in writing to any instrumentality of the District of Columbia government is a criminal offense punishable by criminal penalties.

GOVERNMENT OF THE DISTRICT OF COLUMBIA

DEPARTMENT OF ENERGY AND ENVIRONMENT

UNDERGROUND STORAGE TANKS BRANCH

1200 FIRST STREET, NE, 5TH FLOOR, Washington, D.C. 20002-3315

Phone: (202) 535-2600 FAX: (202) 535-1383 Website: http://doee.dc.gov, Email: UST.DOEE@dc.gov

UNDERGROUND STORAGE TANK

PRESSURE/VACUUM MONITORING FUNCTIONALITY TESTING FORM

I. FACILITY INFORMATION – Type or print (in ink) all items.

Facility ID #: Facility Name:

Facility Street Address:

Facility Telephone: Facility Email: Ward:

II. TESTER INFORMATION

Tester Name: Tester Cert. #: Tester Telephone:

Company Name: Company Cert. #: Test Date:

III. TEST PROCEDURE – Briefly describe procedure(s) used to test the probes (i.e. PEI/RP1200, manufacturer’s testing procedure, etc.)

IV. PRESSURE/VACUUM MONITORING

Tank Number

Product Stored

Line Number1 N/A N/A N/A N/A

ATG Manufacturer

ATG Model

P/V Monitoring System Manufacturer

P/V Monitoring System Model

P/V Monitoring System is functional

Yes No Yes No Yes No Yes No

Manufacturer’s test method followed

Yes No Yes No Yes No Yes No

Interstice is air tight Yes No Yes No Yes No Yes No

Leak in interstice triggers alarm

Yes No Yes No Yes No Yes No

Leak in piping interstice disables

STP2

Yes No N/A Yes No N/A Yes No N/A Yes No N/A

V. TEST RESULT3 Pass Fail Pass Fail Pass Fail Pass Fail

1. Designate each product line that has its interstice under pressure or vacuum by P/V system numerically or by code on the site drawing.

2. Required for pressurized piping systems installed after 2007, using P/V monitoring for 3gph piping release detection.

3. Any “No” answer in a required row indicates the P/V system fails. Failed leak detection systems must be repaired or replaced immediately.

ATTACHMENT 3e

VI. COMMENTS

The comments section should be used to note additional information discovered or actions taken during functionality testing that affect compliance at the facility. For example, include comments concerning any observations made by the tester that would affect the test results.

Include actions taken to repair or replace failed devices.

If additional comment sheets are needed, label each sheet with the report header information and attach the sheet(s) to the back of this form.

VII. SITE DRAWING

Provide a detailed site drawing of the applicable UST(s), product piping, and containment structure layout in the space below (or attach a detailed site drawing prepared on a separate sheet). Any other pertinent information should also be included.

VII. OWNER’S REPRESENTATIVE CERTIFICATION

I have reviewed this report. I certify under penalty of law that the information provided by me is true, accurate, and complete to the best of my knowledge and belief. Pursuant to D.C. Official Code § 22-2405, the making of a false statement in writing to any instrumentality of the District of Columbia government is a criminal offense punishable by criminal penalties.

Signature: Date Signed:

VIII. TESTER CERTIFICATION

By signing this document as the Tester, I certify under penalty of law that the information provided by me is true, accurate, and complete to the best of my knowledge and belief. Pursuant to D.C. Official Code § 22-2405, the making of a false statement in writing to any instrumentality of the District of Columbia government is a criminal offense punishable by criminal penalties.

- 1 OF 2 -

GOVERNMENT OF THE DISTRICT OF COLUMBIA

DEPARTMENT OF ENERGY AND ENVIRONMENT

UNDERGROUND STORAGE TANKS BRANCH

1200 FIRST STREET, NE, 5TH FLOOR, Washington, D.C. 20002-3315

Phone: (202) 535-2600 FAX: (202) 535-1383 Website: http://doee.dc.gov, Email: UST.DOEE@dc.gov

UNDERGROUND STORAGE TANK

SENSOR FUNCTIONALITY TESTING FORM

I. FACILITY INFORMATION – Type or print (in ink) all items.

Facility ID #: Facility Name:

Facility Street Address:

Facility Telephone: Facility Email: Ward:

II. TESTER INFORMATION

Tester Name: Tester Cert. #: Tester Telephone:

Company Name: Company Cert. #: Test Date:

III. TEST PROCEDURE – Briefly describe procedure(s) used to test the sensors (i.e. PEI/RP1200, manufacturer’s testing procedure, etc.)

IV. SENSOR AND TESTING INFORMATION

Sensor Location

Sensor Number1

Manufacturer

Model

Sensor Type Discriminating

Non-Discriminating

Discriminating

Non-Discriminating

Discriminating

Non-Discriminating

Discriminating

Non-Discriminating

Discriminating

Non-Discriminating

Test Liquid Water

Product

Water

Product

Water

Product

Water

Product

Water

Product

Is the ATG console clear of alarms?

Yes No Yes No Yes No Yes No Yes No

Is the sensor properly positioned?

Yes No Yes No Yes No Yes No Yes No

Is the sensor in a good state of repair?

Yes No Yes No Yes No Yes No Yes No

Does the sensor trigger an alarm when placed in the test liquid?

Yes No Yes No Yes No Yes No Yes No

Is the sensor correctly identified on the ATG?

Yes No Yes No Yes No Yes No Yes No

Does a sensor alarm automatically disable the pump? 2

Yes No Yes No Yes No Yes No Yes No

V. TEST RESULT3 Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail

1. Designate each sensor tested numerically or by code on the site drawing.

2. Required for pressurized piping systems installed after 2007, using sensors for 3 gph piping release detection.

3. Failed sensors must be repaired or replaced immediately.

ATTACHMENT 3f

- 2 OF 2 -

VI. COMMENTS

The comments section should be used to note additional information discovered or actions taken during functionality testing that affect compliance at the facility. For example, include comments concerning any observations made by the tester that would affect the test results.

Include actions taken to repair or replace failed devices.

If additional comment sheets are needed, label each sheet with the report header information and attach the sheet(s) to the back of this form.

VII. SITE DRAWING

Provide a detailed site drawing of the applicable UST(s), product piping, and containment structure layout in the space below (or attach a detailed site drawing prepared on a separate sheet). In addition, clearly indicate which sensors were tested. Label each sensor with a unique number or code, used in section V, above. Any other pertinent information should also be included.

VII. OWNER’S REPRESENTATIVE CERTIFICATION

I have reviewed this report. I certify under penalty of law that the information provided by me is true, accurate, and complete to the best of my knowledge and belief. Pursuant to D.C. Official Code § 22-2405, the making of a false statement in writing to any instrumentality of the District of Columbia government is a criminal offense punishable by criminal penalties.

Signature: Date Signed:

VIII. TESTER CERTIFICATION

By signing this document as the Tester, I certify under penalty of law that the information provided by me is true, accurate, and complete to the best of my knowledge and belief. Pursuant to D.C. Official Code § 22-2405, the making of a false statement in writing to any instrumentality of the District of Columbia government is a criminal offense punishable by criminal penalties.

Signature: Date Signed:

- 1 OF 2 -

GOVERNMENT OF THE DISTRICT OF COLUMBIA

DEPARTMENT OF ENERGY AND ENVIRONMENT

UNDERGROUND STORAGE TANKS BRANCH

1200 FIRST STREET, NE, 5TH FLOOR, Washington, D.C. 20002-3315

Phone: (202) 535-2600 FAX: (202) 535-1383 Website: http://doee.dc.gov, Email: UST.DOEE@dc.gov

UNDERGROUND STORAGE TANK

AUTOMATIC TANK GAUGE FUNCTIONALITY TESTING FORM

I. FACILITY INFORMATION – Type or print (in ink) all items.

Facility ID #: Facility Name:

Facility Street Address:

Facility Telephone: Facility Email: Ward

II. TESTER INFORMATION

Tester Name: Tester Cert. #: Tester Telephone:

Company Name: Company Cert. #: Test Date:

III. AUTOMATIC TANK GAUGE Pass Fail

ATG Manufacturer: ATG Model:

Detected leak will trigger an alarm? Yes No Battery Backup Functional? Yes No

ATG software properly programmed? Yes No Is the ATG equipped with CITLDS? Yes No

III. TEST PROCEDURE – Briefly describe procedure(s) used to test the probes (i.e. PEI/RP1200, manufacturer’s testing procedure, etc.)

IV. PROBE AND TESTING INFORMATION

Tank Number

Product Stored

Manufacturer

Model

Measured Product Level (in.)

ATG Product Level (in.)

Measured Water Level (in.)

ATG Water Level (in.)

Measured product and water levels match ATG values?

Yes No Yes No Yes No Yes No Yes No

Is the probe in a good state of repair?

Yes No Yes No Yes No Yes No Yes No

Is the ATG console clear of alarms? Yes No Yes No Yes No Yes No Yes No

Float(s) move freely Yes No Yes No Yes No Yes No Yes No

V. TEST RESULT1 Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail

1. Any “No” answer in a required row indicates the probe fails. Failed probes and ATGs must be repaired or replaced immediately.

ATTACHMENT 3g

- 2 OF 2 -

Facility ID #: Facility Name: Test Date:

VI. COMMENTS

The comments section should be used to note additional information discovered or actions taken during functionality testing that affect compliance at the facility. For example, include comments concerning any observations made by the tester that would affect the test results.

Include actions taken to repair or replace failed devices.

If additional comment sheets are needed, label each sheet with the report header information and attach the sheet(s) to the back of this form.

VII. SITE DRAWING

Provide a detailed site drawing of the applicable UST(s), product piping, and containment structure layout in the space below (or attach a detailed site drawing prepared on a separate sheet). Any other pertinent information should also be included.

VII. OWNER’S REPRESENTATIVE CERTIFICATION

I have reviewed this report. I certify under penalty of law, that the information provided by me is true, accurate, and complete to the best of my knowledge and belief. Pursuant to D.C. Official Code § 22-2405, the making of a false statement in writing to any instrumentality of the District of Columbia government is a criminal offense punishable by criminal penalties.

Signature: Date Signed:

VIII. TESTER CERTIFICATION

By signing this document as the Tester, I certify under penalty of law that the information provided by me is true, accurate, and complete to the best of my knowledge and belief. Pursuant to D.C. Official Code § 22-2405, the making of a false statement in writing to any instrumentality of the District of Columbia government is a criminal offense punishable by criminal penalties.

- 1 -

GOVERNMENT OF THE DISTRICT OF COLUMBIA

DEPARTMENT OF ENERGY AND ENVIRONMENT

UNDERGROUND STORAGE TANKS BRANCH

1200 FIRST STREET, NE, 5TH FLOOR, Washington, D.C. 20002-3315

Phone: (202) 535-2600 FAX: (202) 535-1383 Website: http://doee.dc.gov, Email: UST.DOEE@dc.gov

UNDERGROUND STORAGE TANK

AUTOMATIC LINE LEAK DETECTOR FUNCTIONALITY TESTING FORM

I. FACILITY INFORMATION – Type or print (in ink) all items.

Facility ID #: Facility Name:

Facility Street Address:

Facility Telephone: Facility Email: Ward:

II. TESTER INFORMATION

Tester Name: Tester Cert. #: Tester Telephone:

Company Name: Company Cert. #: Test Date:

III. TEST PROCEDURE – Briefly describe procedure(s) used to test the probes (i.e. PEI/RP1200, manufacturer’s testing procedure, etc.)

IV. LINE LEAK DETECTOR TESTING INFORMATION

Tank Number

Product Stored

Line Number1

Manufacturer

Model

Leak Detector Type Electronic

Mechanical

Electronic

Mechanical

Electronic

Mechanical

Electronic

Mechanical

Electronic

Mechanical

STP Operating Pressure

A. MECHANICAL LINE LEAK DETECTORS

Check Valve Holding Pressure

Metering Pressure

Opening Time

Simulated leak causes slow-flow

Yes No Yes No Yes No Yes No Yes No

Leak detector resets when line pressure is bled off to zero

Yes No Yes No Yes No Yes No Yes No

B. ELECTRONIC LINE LEAK DETECTORS

Simulated leak causes an alarm

Yes No Yes No Yes No Yes No Yes No

Simulated leak disables the STP2

Yes No Yes No Yes No Yes No Yes No

V. TEST RESULT3 Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail

1. Designate each product line, on which a line leak detector was tested, numerically or by code on the site drawing.

2. Required for pressurized piping systems installed after 2007, using LLD for 3gph piping release detection.

3. Any “No” answer in a required row indicates the line leak detector fails. Failed line leak detectors must be repaired or replaced immediately.

ATTACHMENT 3h

- 2 -

VI. COMMENTS

The comments section should be used to note additional information discovered or actions taken during functionality testing that affect compliance at the facility. For example, include comments concerning any observations made by the tester that would affect the test results.

Include actions taken to repair or replace failed devices.

If additional comment sheets are needed, label each sheet with the report header information and attach the sheet(s) to the back of this form.

VII. SITE DRAWING

Provide a detailed site drawing of the applicable UST(s), product piping, and containment structure layout in the space below (or attach a detailed site drawing prepared on a separate sheet). Any other pertinent information should also be included.

VII. OWNER’S REPRESENTATIVE CERTIFICATION

I have reviewed this report. I certify under penalty of law that the information provided by me is true, accurate, and complete to the best of my knowledge and belief. Pursuant to D.C. Official Code § 22-2405, the making of a false statement in writing to any instrumentality of the District of Columbia government is a criminal offense punishable by criminal penalties.

Signature: Date Signed:

VIII. TESTER CERTIFICATION

By signing this document as the Tester, I certify under penalty of law that the information provided by me is true, accurate, and complete to the best of my knowledge and belief. Pursuant to D.C. Official Code § 22-2405, the making of a false statement in writing to any instrumentality of the District of Columbia government is a criminal offense punishable by criminal penalties.

Title 20 District of Columbia Municipal Regulations

65‐1

CHAPTER 65 LICENSING AND CERTIFICATION OF TANK

INSTALLERS, REMOVERS, TESTERS AND OPERATORS

TRAINING REQUIREMENTS

Secs.

6500 General Provisions 6501 Certification Procedures 6502 Operator Training 6503 Approval of Training Programs for Operator Training

6500 GENERAL PROVISIONS

6500.1 The owner or operator of each UST system shall ensure that the UST system or any component of the UST system, including the release detection system, is installed under the continuous on-site supervision of a UST System Technician who is certified in accordance with the provisions of this chapter and who is licensed to do business in the District of Columbia.

6500.2 The owner or operator of each UST system that is to be permanently closed or that the type of service will change shall ensure that the UST system is abandoned or removed under the continuous on-site supervision of a UST System Technician or UST Closer Specialist who is certified in accordance with the provisions of this chapter and who is licensed to do business in the District of Columbia.

6500.3 The owner or operator of each UST system to be tested for tightness shall ensure that the test is conducted under the continuous on-site supervision of a UST System Tester who is certified in accordance with the provisions of this chapter and licensed to do business in the District of Columbia.

6500.4 Each business that provides services for UST system installation, upgrade, retrofit, repair or permanent closure in the District of Columbia shall be certified to perform UST activities by the Director in accordance with the provisions of this chapter and licensed to do business in the District of Columbia. A business may be certified to perform only those UST activities for which it employs a UST System Technician, UST Closer Specialist, UST System Tester who has a current valid District of Columbia certification and license for the applicable UST activity or an equivalent category.

6500.5 Each UST System Technician, UST Closure Specialist and UST System Tester who provides his or her services for UST system installation, upgrade, retrofit, repair, or permanent closure in the District of Columbia shall be certified to perform UST system activities by the Director in accordance with the provisions of this chapter and licensed to do business in the District of Columbia.

6500.6 Each business that is certified to perform UST system activities in the District of Columbia shall provide the Director with a list of employees, who are not certified as UST System Technicians, Closer Specialists or Testers, but who

ATTACHMENT 4

Title 20 District of Columbia Municipal Regulations

65‐2 perform supervised on-site UST activities.

6500.7 Each certified UST System Technician, Closure Specialist and Tester shall carry the identification card or the certificate issued by the Director at all times while conducting the applicable UST activity. The identification card shall be available for inspection by the owner, operator or the Director when the technician, specialist or tester is engaged in the UST activity for which he or she is certified.

6500.8 No business may transfer the UST System certification or license issued to it by the District of Columbia.

6500.9 Within ten (10) business days after close or termination of the business, the licensee shall surrender the certification and license to the Director for cancellation.

6500.10 An owner of any active regulated UST system in the District shall designate at least one Class A, one Class B, and one Class C operator for each active UST facility, and all designated classes shall comply with the requirements of § 6502.

6501 CERTIFICATION PROCEDURES

6501.1 The Director shall certify to perform UST System activities as set forth in §6500 in the District of Columbia, any individuals who satisfy the following requirements:

(a) Show evidence of having satisfactory completion of a recognized training program in the UST System activity(ies) for which the applicant seeks certification;

(b) Submission of a completed application and payment of the initial application fee of $200.00 in the form of a check made payable to the D.C. Treasurer;

(c) Possess a current OSHA certification; and

(d) Satisfactory completion of a test upon their knowledge in the technical area in which they seek certification as well as the District's statutes and regulations pertaining to USTs.

6501.2 The Director shall certify businesses that wish to perform UST System activities in the District of Columbia, as set forth in §6500, provided they satisfy the following requirements:

(a) Submission of a completed application and payment of the initial application fee of $350.00 in the form of a check made payable to the D.C. Treasurer;

Title 20 District of Columbia Municipal Regulations

65‐3

(b) Demonstrate, to the satisfaction of the Director, that the business is qualified to perform the UST System activities for which it seeks certification;

(c) Demonstrate, to the satisfaction of the Director, that the business employs at least one individual who has expertise and is certified in the District in each of the UST System activities the business will offer;

(d) Possess a current OSHA certification; and

(e) Possess a valid, current District of Columbia business license for the business in which certification is sought.

6501.3 The Director may recognize individuals or businesses that are certified by neighboring states and so certify, to perform UST System activities as set forth in § 6500, individuals or businesses that satisfy the requirements of this section:

(a) Possess a current valid certification as a UST System Technician, Closer

Specialist or Tester, or an equivalent certification category as determined by the Director, issued by either of the states of Virginia, West Virginia, Maryland, Delaware, or Pennsylvania;

(b) Are currently in good standing in each of the states, named in

§6501.3(a), for which it holds a certification;

(c) Possess a current OSHA certification;

(d) Possess a valid, current District of Columbia business license for the business in which certification is sought;

(e) Demonstrate, to the satisfaction of the Director, a knowledge of the provisions of this Subtitle; and

(f) Submit a completed application form and pays an initial application fee of $150.00 for individuals or $250 for businesses.

6501.4 An applicant certified in one of the states in §6501.3(a) may be tested by the

Director to verify the knowledge of the provisions of this subtitle or shall submit…