HomeMy WebLinkAbout14143 000303 097 01-04-2021 MOWALK CSW MONTHLY WALKTHROUGH INSPECTION 57509.65 MQWALK
ADEM
30 DAY WALKTHROUGH INSPECTION
CHECKLIST LOG FOR YEAR
Facility Name: owner: _�S )gblo
Address: Address: - �
City, County. Zi _ % City, State , Zi
Facilit I . D. #: / — .� o o ro 3 Phone #: 57
Inspector Name: Inspector Phone #:
Inspector Company:
Instructions
1 . Spill prevention equipment at UST systems receiving deliveries at intervals greater than every 30 days may only be checked prior
to each delivery.
2. Inspection must be performed in accordance with a nationally recognized code of practice (such as PEI RP-900, or equivalent) ,
manufacturer's instructions, or ADEM requirements .
3. Keep a copy of this inspection for 1 year. Questions on how to complete this form should be directed to the Groundwater Branch ,
UST Compliance Section at (334) 270-5655.
Month of Inspection Jan Feb Mar Apr may Jun Jul AugSe Oct Nov Dec
Day of inspection
Spill Containment Equipment (Spill Bucket) Visual Inspection
Evidence of a release
from spill bucket? ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes
(if release found, '� r10 ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no
report it to ADEM
Spill bucket free of yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes
damage'? no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no
Spill bucket free of yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes
water, fuel, and/or
debris? ❑ no ❑ no ❑ no ❑ no I ❑ no ❑ no ❑ no Elno El no ❑ no ❑ no ❑ no
Was water, fuel andlor ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes
debris disposed of ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no
pro pert ? nla ❑ n!a ❑ n1a ❑ nla ❑ n1a ❑ n1a ❑ n1a Cl n1a ❑ nla ❑ nla ❑ n1a ❑ n1a
Is the fill pipe free of §Z1 yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes
obstructions? ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no
Does the fill cap fit P yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes
secure!y on fill pipe? ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no
If double walled spill ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes
bucket, is interstitial ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no
space free of liquid? 9 n1a ❑ n1a ❑ nla ❑ n1a ❑ n/a ❑ n1a ❑ n1a ❑ n1a ❑ n1a ❑ nla ❑ nfa ❑ n1a
Results of spill pass ❑pass ❑pass ❑pass ❑pass ❑pass ❑pass ❑pass ❑pass ❑ pass ❑pass ❑pass
bucket inspection ❑ fail ❑ fail ❑ fail ❑ fail ❑ fail ❑ fail ❑ fail ❑ tall ❑ fail ❑ fail ❑ fail ❑ fail
Inspector's initials
Release Detection Equipment Inspection
Release detection
operating with no PTyes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes
alarms or unusual ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no
operating conditions?
Release detection � yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ yes ❑ es
testing records are
Elsin and current? no El no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no ❑ no El no
Results of RD Opass ❑pass ❑pass ❑pass ❑pass ❑pass ❑pass ❑pass ❑pass ❑pass ❑pass ❑pass
equipment inspection ❑ fail ❑ fail ❑ fail ❑ fail ❑ fail El fail ❑ fail ❑ fail ❑ fail ❑ fail ❑ fail ❑ fail
I
Inspector's initials
Repairs Needed Date of Repair Description of any Repairs
is -- - --- �
` I
ADEM Form 559 3118 m2 (revised 8/ 19)