HomeMy WebLinkAbout5756 006292 081 08-04-2020 ANWALK ALC ANNUAL WALKTHROUGH INSPECTION 57539.53 ANWALK
ADEM
ANNUAL WALKTHROUGH INSPECTION CHECKLIST LOG FOR YEAR 20 2.0
Factlit Name 6 Owner.
Address: L+ it d Address:
CI Cou Zi : '—.s CR .State,Zi
Ins ctor Name: o on r Sid Hertod Ins for Phone#: 334/745-0055
Ins or Com an : u um Environmental-AECT Ins action Dale:
InsWctiom
1. This form allows ycu to record up to 5 ADEM Unique Tank Numbers,assuming at the Facility ID Number remains the same.
2. Complete Portion of forth pertaining to type of equipment inspected for each tank.
nized code of practice(such as PEI RP-900,or equivalent),
3. Inspection must be performed in accordance with a nationally recog
manufacturers instructions,or ADEM requirements.
4. Sites with safe suction piping are not required to complete the containment sump inspection portion of this torte.For sites with safe
suction piping and no hand held release detection equipment,completion
of this
form is not should be directed to Groundwater Branch,
5. Keep a COPY of this inspection for 1 year. Questions on how to comp
lete UST Compliance Section at(334)270-%55.
ADEM Unique Tank#or fS l�y y
Dia near# /S i
Product Stared
lathe Site Using Imam#dal Leak C Yes WitP ❑yes Rho ❑Yes , no C Yes Qno ❑yes no
Detection for Piping?
Visual Condinment Sum Ina Hon
sub pump S b pump ❑sub pump ❑sub pump ❑sub pump
Type of containment sump ❑intermediate ❑intermediate ❑intermediate ❑intermetlia[e ❑intermediate
inspected ❑dis near ❑dis enter Welts nser dis nser 00 tldiss nser
Is the sump an earthen sump? U.yes Wyss 5h a �
❑no ❑no ❑no ❑no ❑no
Is the visible piping in good 64 yes 8 yes RLyes byes 0 yes
❑no ❑no ❑no
cennce,of 0 no 0 no 0 Yes 0 Yes ❑Yes
Is there evidence of I release? C Yes 0 no Gno no ❑no
(If release Sump
it It to ADEM) Styes
E2yes Wye Ayes QYe3
Is the Sump free of damage? 0 no ❑Na ❑no ❑Na ❑In ❑Na ❑no ❑Na ❑no ❑Na
Is the Sump free of water,fuel, Byes Byes Qkrs Dyes dryes
and/or debris? ❑no ❑Na ❑no ❑Na ❑no ❑Na ❑no ❑Na ❑no ❑Na
Water,fuel and/or debris removed 0 Yes ❑Yes 0 yes 0 yes ❑yes
and dis sed of ro it ? 0 no aNa ❑no a ❑no Na ❑no A Na ❑no Na
Are penetrations(boots,conduits, liff yes 12 Yoe yea 0 no
Yea
0
etc, into sum in ootl condition? no ❑N 0 a ❑no ❑Na no ❑We ❑no ❑n/a ❑no ❑me
Is primary piping interstitial space 0 yes 0 yes ❑yes ❑yes 0 yes
open,or test is positionetl,to 0 no n/a ❑no t}n/a ❑no Al n/a ❑no )0 Na ❑no Ants
allow rotluct to erdersum 7 0
Are the sensors Property positioned Oyes ❑yes ❑Yes 0 yes yes
near bottom of sum 7 ❑no Na ❑no Na ❑no Na ❑no H n/a ❑no ff Na
❑ es ❑Yes
If tloWle walled sump,is ❑yes ❑Yss ❑yes Y
interstitial s ace free of li uld? 8-npoasa Na ❑nD°a� �Na 0mpsas n/a amass d Na $.pass bNa
Results of sump inspection 0fail fail pass
0fail ❑fail
Hand Held Release Detection E ui men'Ins lion
❑gauge stick ❑gauge stick ❑gauge stick ❑gauge sliUc ❑gauge Stick
Type of hand held release ❑groundwater ❑groundwater ❑groundwater ❑groundwater ❑groundwater
bals
detection equipment 0 bailer other ci pothers ❑oth bailer bler act : 0 other er bailer
alr
er ci ❑other s cl
Results of equipment 0 pass 0 pass 0 pass 0 pass 0 pass
inspection ❑fall ❑fail 0 fall ❑fail 0 fail
Repairs Needed Date of label r Descr don of an Repalre
Inspector's Signature:
ADEM Form 19 3111 m2(wised 8119)