S02-ATTACHMENT B-IL- OSFM Quarterly AND Annual Equipment Inspection Checklist.pdf

OSFM Quarterly Equipment Inspection Checklist/Operations & Maintenance Guidelines For UST System Inspections

Facility Name: Facility ID:

THIS QUARTERLY INSPECTION IS IN ADDITION TO ALL OTHER MONTHLY RELEASE DETECTION AND TESTING REQUIREMENTS

UST Quarterly Inspection Equipment Items (place check mark in last column if unusual conditions (UC) exist)

CHECKED N/A UC

Section A. Tank Leak Detection Records (Circle applicable number)

1. Automatic Tank Gauge Monthly passing print out tape

2. Interstitial Sensors Monthly status record of normal or equivalent - Annual functional test Last tested: Test due:

3. S.I.R. (Includes Warren Rogers) Monthly status report normal or equivalent

4. Manual Tank Gauging < 600 gal. Weekly stick measurements with monthly reconciliation

5. Manual Tank Gauging 601-2000 Weekly stick measurements with monthly reconciliation - Annual precision test gallons Last tested: Test due:

6. Vapor/Groundwater Monitoring Monthly log with date, results and inspectors’ initials

7. Water in Tank Monitor ATG for water alarm or check tank utilizing gauge stick and water paste

Section B. Tank Component Inspection

1. Tank Monitoring System Ensure system has power and is in a normal status with no alarms (daily)

2. Submersible Sump Covers Ensure all covers are present, in good condition and seated firmly

3. Submersible Sump Ensure no water is in submersible sump that contains interstitial sensors If piping is single wall and corrosion prevention is installed, water is allowed

4. Electrical Ensure junction boxes are intact and no obvious wire breaks are visible

Section C. Piping Leak Detection Records (Circle applicable number)

1. Interstitial Sensors Monthly status record of normal or equivalent - Annual functional test Last tested: Test due:

2. Mechanical Line Leak Detector Annual precision test of lines and functionality test of leak detector Last tested: Test due:

3. Electronic Line Leak Detector If proof of annual 0.1 gph system leak test is performed, a functionality test of the leak detector is required only - If proof is not available a precision line test will also have to be performed Last tested: Test due:

Section D. Piping Component Inspection (Circle applicable number)

1. Pressurized piping components Ensure line leak detector is in place, if interstitial sensors are used, ensure they are positioned at the lowest portion of the submersible and dispenser sump

2. American Suction Ensure monthly monitoring is in place

3. Product Piping Inspect for obvious leaks, deformations, cracks or other abnormalities

Section E. Corrosion Protection Records (Circle applicable number)

1. Impressed Current System Monthly log with date, initials of inspector, hour, volt, amp and power on verification - Annual system test: Last tested: Test due:

2. Sacrificial Anode System System must be tested every 3 years: Last tested: Test due:

3. Internal Lining Must be inspected every 5 years: Last tested: Test due:

Section F. Corrosion Component Inspection (Circle applicable number)

1. Impressed Current System Ensure rectifier has power and power light functions, observe and record volt, amp and hour meter readings

2. Sacrificial Anodes If anodes and connections are visible in submersible or dispenser sumps, observe for obvious connection breaks of wiring from steel components

Section G. Spill Protection

1. Spill Protection Equipment Ensure spill containment is in place, clean, dry & no obvious cracks/tears (daily)

Section H. Overfill

1. Automatic Shutoff Ensure device is in place and free of restrictive items

2. Overfill Alarm Ensure device is in place and test function operates properly

Section I. Dispensers and Emergency Shut-Offs

1. Hose and Nozzle Components Observe for obvious leaks, cracks & deformations. Ensure breakaway is installed

2. Under dispenser Ensure shear valve is in place and properly anchored. Observe for obvious leaks

Ensure interstitial sensors if installed are positioned at the lowest portion

Observe for obvious open electrical junction boxes or broken wiring

Section J. Emergency Shut-Off

1. Emergency Shut-Off Ensure emergency shut offs are accessible and have no obvious damage Last tested: Test due:

Section K. Emergency Actions

1. System Alarms Ensure any alarms have been reported as required by facility operations plan

2. Spills, Leaks or Release Ensure any release has been reported as required by facility operations plan

Remarks needed if unusual conditions exist (also include the date owner was notified and actions taken):

Verify that each monthly recordkeeping requirement on the 1st page has been accomplished by initialing in the blanks below. (Initial all that are applicable)

Tank Leak Detection/Interstitial Monitoring Jan Feb March April May June July Aug Sept Oct Nov Dec

Line Interstitial Monitoring/Automatic Line Leak Detectors

Impressed Current System

Additional Daily, Monthly, Quarterly, and Annual Inspection Items (indicate how often):

Daily:

Monthly:

Quarterly:

Annually: Submit annual Financial Responsibility Report from www.sfm.illinois.gov at Applications & Forms.

Identify the manner in which facility owners/operators will properly dispose of regulated substances spilled at the facility:

A/B Operators must conduct the quarterly inspections personally. Sign & date the form when inspection is done.

If using this form as part of your Operations & Maintenance Plan, attach the list of your class A/B & C Operators & your facility's Emergency Response Procedures form. The facility Owner must sign the O&M Plan with the A/B Operator, but only the A/B Operator is required to sign the Quarterly Inspection report.

Signature of Owner Signature of A/B Operator Date of Inspection http://www.sfm.illinois.gov/

State of Illinois Office of the State Fire Marshal

Annual Walkthrough Inspection Report: 20 (year)

Inspections Required Annually (Inspections of piping sump areas must be performed by a certified employee of a licensed contractor. All piping sumps areas shall be checked annually, and lids must be lifted, and dispenser cabinets opened to inspect piping containment sump areas.)

Contractor must initial and enter date of Annual Walkthrough Inspection.

Day/Month/Year of Inspection

Contractor Initials

Enter comments below corresponding to inspections listed at left.

Visual check for damage to piping containment sump areas: Check lids, covers & containment for damage & leaks.

COMMENTS & ACTIONS TAKEN:

Check sumps for the presence of regulated substances or any indication that a release may have occurred. Remove any liquid or debris if present.

COMMENTS & ACTIONS TAKEN:

Check that interstices of double wall containment sumps are free of water or product.

COMMENTS & ACTIONS TAKEN:

If applicable: Check gauge stick (manual tank gauging) or bailer (GW monitoring).

COMMENTS & ACTIONS TAKEN:

Contractor Employee Conducting Annual Inspection of Piping Containment Sump Areas:

1) Signature:

2) Print Name & Title:

Annual Test & Inspection: May be Performed by Contractor or A/B Operator Contractor or A/B Operator must initial and enter date of Annual Emergency Stops Test.

Day/Month/Year of Emergency Stop Test

Contractor or A/B Operator Initials

Enter comments below regarding Annual Emergency Stops Test. Attach OSFM Operational Testing of Emergency Stops Report to Walkthrough Inspection Report & keep at facility.

Test Emergency Stops for interconnection and STP shutdown.

Attach OSFM report form.

COMMENTS:

Contractor or A/B Operator must initial and enter date of Annual Shear Valve Inspection.

Day/Month/Year of Shear Valve Inspection

Contractor or A/B Operator Initials

Enter comments below regarding Annual Shear Valve Inspection. Attach OSFM Annual Inspection of Shear Valves Report to Walkthrough Inspection Report & keep at facility.

Check shear valves for proper height, secure mounting & free operation of trip arm & poppet.

COMMENTS:

p&cs 5/2018