Monthly walkthrough inspection form
|[pic] |Monthly walkthrough |
| |inspection form |
| |Underground Storage Tanks (UST) Program |
| |Doc Type: Compliance Certification |
Purpose: This form is to be used to document the monthly walkthrough inspections.
Facility information
|Facility name: | |
|Facility address: | |Facility ID#: | |
|City: | |State: | |Zip code: | |
Testing information
|1. Tank number | | | | | | |
|2. Product stored | | | | | | |
|3. Tank volume, gallons | | | | | | |
|Spill buckets | | | | | | |
|5. Is the spill bucket free of fuel, water or | Yes No | Yes No | Yes No | Yes No | Yes No | Yes No |
|debris? | | | | | | |
|6. Is the spill bucket free of cracks, holes, | Yes No | Yes No | Yes No | Yes No | Yes No | Yes No |
|bulges, or other defects? | | | | | | |
|7. Is the riser cap secure and in good condition?| Yes No | Yes No | Yes No | Yes No | Yes No | Yes No |
|8. Is the drop tube free of obstructions? | Yes No | Yes No | Yes No | Yes No | Yes No | Yes No |
|9. If the spill bucket is double-walled is the | Yes No | Yes No | Yes No | Yes No | Yes No | Yes No |
|interstice free of leaks? |NA |NA |NA |NA |NA |NA |
|10. If “No” answered for any line from 4-9 have | Yes No | Yes No | Yes No | Yes No | Yes No | Yes No |
|corrective actions been completed?* |NA |NA |NA |NA |NA |NA |
|Dispensers | | | | | | |
|12. Is the dispenser sump free of cracks, holes, | Yes No | Yes No NA | Yes No NA | Yes No | Yes No NA | Yes No NA |
|bulges, or other defects? |NA | | |NA | | |
|13. Are the piping, flexible connectors and | Yes No | Yes No | Yes No | Yes No | Yes No | Yes No |
|meters free of leaks or seeps? | | | | | | |
|14. Is hanging hardware free of leaks or seeps? | Yes No | Yes No | Yes No | Yes No | Yes No | Yes No |
|15. If the dispenser sump is double-walled is the| Yes No NA | Yes No NA | Yes No NA | Yes No NA | Yes No NA | Yes No NA |
|interstice free of leaks? | | | | | | |
|16. Are shear valves securely anchored? | Yes No | Yes No | Yes No | Yes No | Yes No | Yes No |
|17. If “No” answered for any line from 11-16 have| Yes No | Yes No NA | Yes No NA | Yes No | Yes No NA | Yes No NA |
|corrective actions been completed?* |NA | | |NA | | |
|Submersible turbine pump sumps | | | | | | |
|19. Is the STP sump free of cracks, holes, bulges| Yes No | Yes No NA | Yes No NA | Yes No | Yes No NA | Yes No NA |
|or other defects? |NA | | |NA | | |
|20. Are the STP components, piping and flexible | Yes No | Yes No | Yes No | Yes No | Yes No | Yes No |
|connectors free of leaks or seeps? | | | | | | |
|21. If the STP sump is double-walled is the | Yes No | Yes No NA | Yes No NA | Yes No | Yes No NA | Yes No NA |
|interstice free of leaks? |NA | | |NA | | |
|22. If “No” answered for any line from 18-21 have| Yes No | Yes No | Yes No | Yes No | Yes No | Yes No |
|corrective actions been completed?* |NA |NA |NA |NA |NA |NA |
|Release detection equipment | | | | | | |
|24. Is the release detection equipment operating | Yes No | Yes No | Yes No | Yes No | Yes No | Yes No |
|with any unusual operating conditions? | | | | | | |
|25. Do release detection records indicate a | Yes No | Yes No | Yes No | Yes No | Yes No | Yes No |
|passing test? | | | | | | |
|26. Are release detection records current? | Yes No | Yes No | Yes No | Yes No | Yes No | Yes No |
|27. Is the gauging stick in good condition? | Yes No | Yes No | Yes No | Yes No | Yes No | Yes No |
| |NA |NA |NA |NA |NA |NA |
|28. Has the UST been checked for the presence of | Yes No | Yes No | Yes No | Yes No | Yes No | Yes No |
|water? | | | | | | |
|29. What is the level of water in the UST? | | | | | | |
|30. If Yes answered for lines 23 – 24 or | Yes No | Yes No | Yes No | Yes No | Yes No | Yes No |
|No answered for lines 25 – 28, have corrective |NA |NA |NA |NA |NA |NA |
|actions been completed?* | | | | | | |
*Describe corrective actions taken in the comments section.
|Comments: |
| |
|Company: | |Print Inspectors name: | |
|Date (mm/dd/yyyy): | |Signature: | |
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