Title Page
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Site
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Facility Sign
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Location
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API
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Location Type
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County
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State
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Inspection Type
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Frequency
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Conducted on
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Prepared by
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Were any leaks found associated with thief hatches, closed vent systems, pumps, compressors, pressure relief devices, open-ended valves or lines, valves, flanges, connectors, piping, and associated equipment?
Leaks
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Equipment Type
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Leaking Component
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Leak Description
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Leak Picture
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Initial Repair Attempt Made?
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Repair Successful?
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Leak Repair Delayed?
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What is reasoning leak repair was delayed?
Pneumatic Controllers and Pumps
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Does the facility have gas-driven pneumatic pumps or controllers?
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Has the Pneumatic Pump or Controller been inspected for leaks and proper working order?
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Were any leaks on the controller or pump and associated piping and connections noted during inspection?
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Were leaks repaired?
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Will the leak be repaired within 30 days?
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Is the pneumatic pump or controller operating normally?
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Describe repairs made to controller or pump.
Storage Vessels
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Does this facility have any storage tanks subject to the requirements in 20.5.50.123
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Was a AVO inspection of the storage tank performed?
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Did the inspection find any evidence of leaks in the storage tank, hatch, or associated piping and gaskets?
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Describe the leak found
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Was the leak able to be repaired?
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Will the leak be repaired within 30 days?
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Describe the reasoning for the delay in leak repair.
Control Devices
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Did the leak inspection include a flare, enclosed combustion device (ECD), thermal oxidizer (TO) or a vapor recovery unit (VRU)?
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Were any leaks discovered during the inspection of this control system?
Inspector Verification
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Signature