TE7 STAR Inspection Checklist Forms.pdf

TANK COMPLIANCE ASSESSMENT CHECKLIST

ANNUAL ORGANIZATIONAL TANK ASSESSMENT

Installation Date:

Real Property ID:

Installation/GSU:

Owner:

Unit/Org: Designation:

Location: Volume (Gallons):

Model: Contents:

Serial #:

Finding Status:

Perform Date: Status:

Assessor: Duty Phone:

Conclusion:

Comments:

For Official Use Only

TANK CONTAINMENT

Are there water accumulations, debris, vegetation, cracks, fire hazards, or holes observed in the tank containment?

Correct Response: NResponse: Yes No N/A

Comments:

Are containment drain valves in working order and closed?

Correct Response: YResponse: Yes No N/A

Comments:

TANK FOUNDATION AND SUPPORTS

Is there evidence of tank settlement, foundation washout, or foundation cracking?

Correct Response: NResponse: Yes No N/A

Comments:

Is there any cracking, spalling, or corrosion of tank supports and/or saddles?

Correct Response: NResponse: Yes No N/A

Comments:

Are ladders, platforms, handrails, and stairs secure with no indication of corrosion and/or damage?

Correct Response: YResponse: Yes No N/A

Comments:

TANK AND APPURTENANCES

Is the normal vent clear and free of obstructions?

Correct Response: YResponse: Yes No N/A

Comments:

Is vent located five feet or more from adjacent buildings?

Correct Response: YResponse: Yes No N/A

Comments:

For class I fuels (ie MOGAS, AVGAS), are normal vents located at least 12 feet above grade?

Correct Response: YResponse: Yes No N/A

Comments:

For Official Use Only

TANK AND APPURTENANCES (continued)

Are there emergency vents for the primary tank?

Correct Response: YResponse: Yes No N/A

Comments:

If the primary tank is equipped or designed with an emergency vent, is it operable (vent cover can be lifted by hand)?

Correct Response: YResponse: Yes No N/A

Comments:

If a secondary tank is present and equipped or designed with an emergency vent, is it operable (vent cover can be lifted by hand)?

Correct Response: YResponse: Yes No N/A

Comments:

If the primary tank is equipped or designed with a pressure vacuum vent, is it operable?

Correct Response: YResponse: Yes No N/A

Comments:

Are all valves in working order?

Correct Response: YResponse: Yes No N/A

Comments:

Are NFPA-compliant placards present and legible?

Correct Response: YResponse: Yes No N/A

Comments:

CORROSION CONTROL

Is there any evidence of paint coating failure or corrosion of tank and piping surfaces?

Correct Response: NResponse: Yes No N/A

Comments:

Is there evidence of corrosion at pipestand and piping interfaces (undercutting of pipe) including underside of piping?

Correct Response: NResponse: Yes No N/A

Comments:

Is there cathodic protection for underground metallic piping?

Correct Response: YResponse: Yes No N/A

Comments:

Is cathodic protection working and being checked regularly?

Correct Response: YResponse: Yes No N/A

Comments:

LEVEL AND OVERFILL PREVENTION

Has the tank level indicating device been tested and is it in working order?

Correct Response: YResponse: Yes No N/A

Comments:

Is tank level gauge viewable from the filling point?

Correct Response: YResponse: Yes No N/A

Comments:

1550424661A Cross-Out

For Official Use Only

LEVEL AND OVERFILL PREVENTION (continued)

Has the overflow shutoff mechanism (shut off valve or float valve) been tested to determine if it is in good working order?

Correct Response: YResponse: Yes No N/A

Comments:

If a High Level Alarm is present, has it been tested to determine if it is in good working order?

Correct Response: YResponse: Yes No N/A

Comments:

Are anti-siphon valves operable (if present)?

Correct Response: YResponse: Yes No N/A

Comments:

ELECTRICAL WIRING AND EQUIPMENT

Is the tank grounded?

Correct Response: YResponse: Yes No N/A

Comments:

Are grounding straps secure and in good order?

Correct Response: YResponse: Yes No N/A

Comments:

Are wiring, wiring conduit, and junction boxes in good condition?

Correct Response: YResponse: Yes No N/A

Comments:

Are electrical components in classified conduit and enclosures as required?

Correct Response: YResponse: Yes No N/A

Comments:

TANK SITE

Are traffic bollards and/or protection from vehicle traffic in place where required?

Correct Response: YResponse: Yes No N/A

Comments:

ADDITIONAL

Have all other Local, State, or Federal requirements checklist(s) been accomplished, if required, and documents uploaded to this tank record? Provide appropriate reference to record in comments.

Correct Response: YResponse: Yes No N/A

Inspector Signature

MONTHLY ORGANIZATIONAL TANK ASSESSMENT

Installation Date:

Real Property ID:

Installation/GSU:

Owner:

Unit/Org: Designation:

Location: Volume (Gallons):

Model: Contents:

Serial #:

Finding Status:

Perform Date: Status:

Assessor: Duty Phone:

Conclusion:

Comments:

For Official Use Only

TANK CONTAINMENT

Are there water accumulations, debris, vegetation, cracks, fire hazards, or holes observed in the tank containment?

Correct Response: NResponse: Yes No N/A

Comments:

Are containment drain valves in working order and closed?

Correct Response: YResponse: Yes No N/A

Comments:

If the tank is a double wall tank, was there water or fuel in the tank interstitial space?

Correct Response: NResponse: Yes No N/A

Comments:

Are there leaks, broken seals, and/or corrosion of manhole covers?

Correct Response: NResponse: Yes No N/A

Comments:

Are there any indications of leakage, staining, seepage, or corrosion around tank shell or concrete pad?

Correct Response: NResponse: Yes No N/A

Comments:

Are there any indications of leakage, staining, seepage, or corrosion on piping, pipe connections, or pipe stands?

Correct Response: NResponse: Yes No N/A

Comments:

Are there any indications of leakage, staining, seepage, or corrosion on valves?

Correct Response: NResponse: Yes No N/A

Comments:

Are there any indications of leakage, staining, seepage, or corrosion on tank supports/saddles?

Correct Response: NResponse: Yes No N/A

MONTHLY ORGANIZATIONAL TANK ASSESSMENT

For Official Use Only

TANK CONTAINMENT (continued)

Is the tank level gauge working, readable, and can be observed by the operator from the fill position location?

Correct Response: YResponse: Yes No N/A

Comments:

Are ladders, platforms, handrails, and stairs secure with no indication of severe corrosion and/or damage?

Correct Response: YResponse: Yes No N/A

Comments:

Are containment egress (exit) pathways clear?

Correct Response: YResponse: Yes No N/A

Comments:

Are gates/doors operable and in working order?

Correct Response: YResponse: Yes No N/A

Comments:

Are fire extinguishers maintained in a serviceable condition and located in the designated area?

Correct Response: YResponse: Yes No N/A

Comments:

Has an AF Form 332 been completed for any deficiencies observed?

Correct Response: YResponse: Yes No N/A

Comments:

Are NFPA-compliant placards present and legible?

Correct Response: YResponse: Yes No N/A

Comments:

ADDITIONAL

Have all other Local, State, or Federal requirements checklist(s) been accomplished, if required, and documents uploaded to this tank record? Provide appropriate reference to record in comments.

Correct Response: YResponse: Yes No N/A

ANNUAL UST INSPECTION

Installation Date:

Real Property ID:

Installation/GSU:

Designation:

Location:

Volume (Gallons):

Contents:Model:

Finding Status:

Perform Date: Status:

Assessor: Duty Phone:

Conclusion:

Comments:

For Official Use Only

SECONDARY CONTAINMENT SUMPS (SUBMERSIBLE TURBINE PUMP, DISPENSER, TRANSITION)

Are containment sumps free of damage?

Correct Response: YResponse: Yes No N/A

Comments:

Are containment sumps free of leaks to the containment area and without indication of a release to the environment?

Correct Response: YResponse: Yes No N/A

Comments:

Are containment sumps free of water, product and debris? Liquid and debris must be removed and disposed of properly.

Correct Response: YResponse: Yes No N/A

Comments:

HAND-HELD RELEASE DETECTION EQUIPMENT

Do hand-held release detection equipment (e.g. groundwater bailers and tank gauge sticks) accurately measure liquid depth?

Correct Response: YResponse: Yes No N/A

Comments:

DISPENSERS

Are dispenser hoses, nozzles and breakaways free of loose fittings, deterioration, signs of leakage, or improper functionality?

Correct Response: YResponse: Yes No N/A

Comments:

EQUIPMENT TESTING

Is annual piping testing complete with passing results? (Ref: 40 CFR 280.41)

Correct Response: YResponse: Yes No N/A

Comments:

Is triennial spill bucket and containment sump testing complete with passing results? (Ref: 40 CFR 280.35)

Correct Response: YResponse: Yes No N/A

Comments:

Unit/Org:

Serial #:

ANNUAL UST INSPECTION

For Official Use Only

EQUIPMENT TESTING (continued)

Is triennial overfill equipment (Automatic Shutoff Device and Alarm) verification, inspection, and testing complete with passing results?

(Ref: 40 CFR 280.35)

Correct Response: YResponse: Yes No N/A

Comments:

Is annual electronic monitoring system (Automatic Tank Gauging - ATG and liquid sensors) inspection and testing complete with passing results? (Ref: 40 CFR 280.40)

Correct Response: YResponse: Yes No N/A

Comments:

Is annual line leak detector testing complete with passing results? (Ref: 40 CFR 280.40, 280.44)

Correct Response: YResponse: Yes No N/A

Comments:

ADDITIONAL

Have all other Local, State, or Federal requirements checklist(s) been accomplished, if required, and documents uploaded to this tank record? Provide appropriate reference to record in comments.

Correct Response: YResponse: Yes No N/A

MONTHLY UST INSPECTION

Installation Date:

Real Property ID:

Installation/GSU:

Designation:

Location: Volume (Gallons):

Model: Contents:

Serial #:

Finding Status:

Perform Date: Status:

Assessor: Duty Phone:

Conclusion:

Comments:

For Official Use Only

SPILL PREVENTION EQUIPMENT

Is spill prevention equipment (e.g. spill buckets) in good working condition and capable of containing spills?

Correct Response: YResponse: Yes No N/A

Comments:

Is spill prevention equipment free of corrosion?

Correct Response: YResponse: Yes No N/A

Comments:

Is spill prevention equipment free of water, product, or debris? Liquid and debris must be removed and disposed of properly.

Correct Response: YResponse: Yes No N/A

Comments:

Is fill pipe free of obstructions (i.e. gauging stick segments, trash, debris etc.)? Any obstructions must been removed.

Correct Response: YResponse: Yes No N/A

Comments:

Is the fill cap in good condition and equipped with an intact gasket?

Correct Response: YResponse: Yes No N/A

Comments:

Does the fill cap and its assembly fit securely on the fill pipe before, during, and after deliveries?

Correct Response: YResponse: Yes No N/A

Comments:

Is double-walled spill prevention equipment interstitial area free from leaks? (Applicable only to double-walled spill prevention equipment)

Correct Response: YResponse: Yes No N/A

Comments:

RELEASE DETECTION EQUIPMENT

If the tank is equipped with release detection, is the equipment operating properly to determine usual operating conditions (i.e., faulty alarms, monitoring discrepancies, readings, etc.)?

Correct Response: YResponse: Yes No N/A

Comments:

Owner:

Unit/Org:

MONTHLY UST INSPECTION

For Official Use Only

RELEASE DETECTION EQUIPMENT (continued)

If the piping is equipped with release detection, is the equipment operating properly to determine usual operating conditions (i.e., faulty alarms, monitoring discrepancies, readings, etc.)?

Correct Response: YResponse: Yes No N/A

Comments:

Have copies of release detection reports been obtained, for each tank system, to meet record keeping requirements?

Correct Response: YResponse: Yes No N/A

Comments:

Has the Impressed Current Rectifier Check been conducted and results documented within the last 60 days?

Correct Response: YResponse: Yes No N/A

Comments:

ADDITIONAL

Have all other Local, State, or Federal requirements checklist(s) been accomplished, if required, and documents uploaded to this tank record? Provide appropriate reference to record in comments.

Correct Response: YResponse: Yes No N/A