Monthly UST Inspection

• Audit Title

• Client / Site

• Facility ID Number

• Location
  Address

• Conducted on

  Date

• Prepared by

  Nate Antieau

  Christine Caddick

  Pete Dahlgren

  George Ontko

  Brad Ziegler

• Personnel

  Select Nate Antieau Christine Caddick Pete Dahlgren George Ontko Brad Ziegler

  • Nate Antieau
  • Christine Caddick
  • Pete Dahlgren
  • George Ontko
  • Brad Ziegler

Documentation

• Is a Registration Certificate posted and current?

  Current

  Expired

  Not Posted

• Expiration Date (as indicated in the body, NOT the upper corner).

  Date

• Financial Responsibility current?

  Yes

  No

  Not Available

• Expiration Date

  Date

• To add comments related to Documentation, check here.

• Comments

• Add media

  Media

Dispenser Area

• If there are NO DISPENSERS as part of this system check here.

• If there are NO Dispenser SUMPS, check here.

• Internal Piping/Components

• Is any metal piping or braided metal flex in direct contact with soil or debris, without cathodic protection attached?

  No

  Yes

• No leaks from any piping, filters, or other components of the system?

  Yes

  No

• No abnormal appearance of piping or components (rust, discoloration, delamination, swelling, deterioration)?

  Yes

  No

• Product Shear Valve (only required on pressure systems): Properly secured and anchored, installed at proper level, with no leaks?

  Yes

  No

  N/A

• Dispenser Sumps

• Clean and empty: No water, product, or debris?

  Yes

  No

• Sump Integrity: No cracks,bulges, or holes?

  Yes

  No

• If double wall piping, is test boot pulled back so interstice is unobstructed?

  Yes

  No

  N/A

• Internal Piping/Components

• If any dispenser does NOT have a sump, check here.

• Is any metal piping or braided metal flex in direct contact with soil or debris, without cathodic protection attached?

  No

  Yes

• No leaks from any piping, filters, or other components of the system?

  Yes

  No

• No abnormal appearance of piping or components (rust, discoloration, delamination, swelling, deterioration)?

  Yes

  No

• Product Fire/Impact Valve (only required on pressure systems): Properly secured and anchored, installed at proper level, with no leaks?

  Yes

  No

  N/A

• External Components

• No damage to, or deterioration of hoses, filters, or nozzles?

  Yes

  No

• Splash guards, breakaway devices present and in working order?

  Yes

  No

• Signage (Warning, No Smoking, Fuel Identification) present and legible?

  Yes

  No

• Miscellaneous Items

• Is Emergency Shut-Off button present?

  Yes

  No

  N/A

• Fire Extinguisher within 100 feet?

  Yes

  No

• Properly charged and inspected (annual inspection required)

  Yes

  No

• Area surfaces free of granular absorbent?

  Yes

  No

• No dispensers present as part of this system.

• To add comments related to the Dispenser Area, check here.

• Dispenser Area Comments

• Add media

  Media

Leak Detection Methods/Equipment

• If non-ATG Automatic Interstitial Monitoring Device, or if Automatic Interstitial Monitoring is included in function of ATG, check Sensor Status monthly. Inspect piping sumps quarterly, or whenever sensors are not normal. If Manual Interstitial Monitoring is leak detection method, or if there are no sensors in piping sumps, piping sumps should be inspected monthly.

• Select method(s) of release detection

  Select ATG Non-ATG Automatic Interstitial Monitoring Device Manual Interstitial Monitoring Automatic Line Leak Detection (pressure systems only) Groundwater Monitoring Soil Vapor Monitoring

  • ATG
  • Non-ATG Automatic Interstitial Monitoring Device
  • Manual Interstitial Monitoring
  • Automatic Line Leak Detection (pressure systems only)
  • Groundwater Monitoring
  • Soil Vapor Monitoring

• ATG (with/without Automatic Interstitial Monitoring)

• Leak test pass (0.2 gph periodic or CSLD/SCALD)?

  Yes

  No

  N/A

• No current sensor alarms

  Yes

  No

• Alarm history clear of alarms (past month)

  Yes

  No

  N/A

• Are tank interstitial sensors normal?

  Yes

  No

  N/A

• Are piping sump sensors normal?

  Yes

  No

  N/A

• Paper loaded (if applicable)

  Yes

  No

  N/A

• Automatic Interstitial Monitoring Device (non ATG)

• Device operational, with no alarms on tank interstitial sensors, or piping sump sensors?

  Yes

  No

• Manual Interstitial Monitoring (See Piping Containment Sumps item in Tank Area Section below).

• Automatic Line Leak Detection

• No leaks in the leak detector(s)?

  Yes

  No

  N/A

• Groundwater Monitoring

• Cover(s) clearly marked and secured?

  Yes

  No

• Water present in well(s)?

  Yes

  No

• No product present in well(s)?

  Yes

  No

• Soil Vapor Monitoring

  Yes

  No

  N/A

• Cover(s) clearly marked and secured?

  Yes

  No

• To add comments related to Leak Detection Methods/Equipment, check here.

• Leak Detection Methods/Equipment Comments

• Add media

  Media

Tank Area

• Overfill Protection

• Select method(s) of Overfill Protection present. Overfill alarm is horn/strobe mounted somewhere in area of fuel fill. Automatic shut off device is mounted in fuel fill tube.

  Select Overfill Alarm Automatic Shut Off None Observed

  • Overfill Alarm
  • Automatic Shut Off
  • None Observed

• Overfill Alarm

• Are both audio and visual portions functional and within sight/hearing from fill port?

  Yes

  No

• Signage present (alerting bulk fuel delivery person to overfill devices in use)

  Yes

  No

• Automatic Shut Off Device

• Signage present (alerting bulk fuel delivery person to overfill devices in use)

  Yes

  No

• No Overfill Protection observed

• Spill Containment Sumps (Spill Buckets)

• Cover is in good condition and properly identified.

  Yes

  No

• Sump clean, empty, dry, and in good condition.

  Yes

  No

• Piping and components are in good condition, and cap seals tightly.

  Yes

  No

• Is coaxial vapor recovery present on fuel fill pipe?

  Yes

  N/A

• Piping Containment Sumps (Check here if present) If Automatic Interstitial Monitoring, inspect only quarterly, unless sensor(s) in alarm.

• Piping Containment Sumps

• Cover is in good condition.

  Yes

  No

• Secondary cover is in good condition and seals to sump.

  Yes

  No

  N/A

• Sump is clean, empty, dry, and in good condition.

  Yes

  No

• Sump sensors present, at correct position/height, and operational.

  Yes

  No

  N/A

• If braided metal flex is present, there are no leaks and it is not in contact with soil or debris.

  Yes

  No

  N/A

• Venting Equipment

• Pressure/Vacuum vent cap present

  Yes

  No

• Dual Point, Stage I Vapor Recovery ports (Check here if present).

• Vapor Recovery (Dual Point- Stage I)

• Cover in good condition and properly identified.

  Yes

  No

• Sump (if present) is empty, dry, and in good condition.

  Yes

  No

  No sump

• Poppet cap is tightly sealed.

  Yes

  No

• Poppet seals tightly and moves freely when depressed.

  Yes

  No

• To add comments related to the Tank Area, check here.

• Tank Area Comments

• Add media

  Media

Corrosion Protection (if required)

• Impressed Current Cathodic Protection (Check here if installed).

• No Impressed Current device.

• Rectifier is operating within normal limits.

  Yes

  No

Miscellaneous Items

• Spill Kits: Appropriate and sufficient materials present?

  Yes

  No

  N/A

• To add Comments, check here.

• Comments

• Add media

  Media

• To add a sketch, check here.

• Sketches

Sketch

• Sketch

  Drawing

Certification

• Signature

  Sign