HomeMy WebLinkAbout12730 009494 101 12-02-2020 ANWALK SLA ANNUAL WALKTHROUGH INSPECTION 72091.05 ANWALK
ADEM
ANNUAL WALKTHROUGH INSPECTION CHECKLIST LOG FOR YEAR
Facility Name: Owner:
Address: Address:
City, County,Zip, City, State, Zip,
Facility I.D.#: Phone#:
Inspector Name: Inspector Phone#:
Inspector Company: Inspection Date:
Instructions
1. This form allows you to record up to 5 ADEM Unique Tank Numbers,assuming that the Facility ID Number remains the same.
2. Complete portion of form pertaining to type of equipment inspected for each tank.
3. 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.
4. Sites with safe suction piping are not required to complete the containment sump inspection portion of this form.For sites with safe
suction piping and no hand held release detection equipment,completion of this form is not required.
5. 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.
ADEM Unique Tank 0 or
Dis enser Will
Product Stored
Is the Site Using Interstitial Leak
Detection for PI in 7 D Yes ❑no ❑yes ❑ no ❑yes ❑no ❑yes ❑ no ❑yes ❑ no
Visual Containment Sump Inspection
Type of containment sump D sub pump ❑sub pump ❑sub pump ❑sub pump ❑sub pump
inspected ❑intermediate ❑intermediate ❑intermediate ❑intermediate ❑intermediate
❑dispenser ❑dispenser ❑dispenser ❑dispenser ❑dispenser
Is the sump an earthen sump? D Yes ❑yes ❑yes ❑yes ❑yes
❑no ❑no ❑no ❑no ❑no
Is the visible piping in good ❑yes ❑yes ❑yes ❑yes ❑yes
condition? ❑no ❑no ❑no ❑no ❑no
Is there evidence of a release? ❑yes ❑yes ❑yes ❑yes ❑yes
If release found,report it to ADEM ❑no ❑no ❑no ❑no ❑no
Is the Sump free of damage? 13 yes ❑yes ❑yes ❑yes ❑yes
❑no ❑n/a ❑no ❑We ❑no ❑n/a ❑no ❑We ❑no ❑n/a
Is the Sump free of water,fuel, ❑yes ❑yes ❑yes ❑yes ❑yes
and/or debris? ❑no ❑n/a ❑no ❑n1al ❑no ❑n/a ❑no ❑We ❑no ❑n/a
Water,fuel and/or debris removed ❑yes ❑yes ❑yes ❑yes ❑yes
and disposed of proiperl 13 no ❑n/a ❑no ❑n/a ❑no ❑n/a ❑no ❑n/a ❑no ❑n/a
Are penetrations(boots,conduits, ❑yes ❑yes ❑yes ❑yes ❑yes
etc.)into sump in good condition? ❑no ❑Na ❑no ❑n/a ❑no ❑ n/a ❑no ❑n/a ❑no ❑Na
Is primary piping interstitial space p yes ❑yes ❑yes ❑yes ❑yes
open,or test boots positioned,to p no ❑n/a ❑no ❑n/a ❑no ❑ n/a ❑no ❑n/a ❑no ❑n/a
allow product to enter sump;
Are the sensors properly positioned ❑yes ❑yes ❑yes ❑yes ❑yes
near bottom of sump? ❑no ❑n/a ❑no ❑n/a ❑no ❑ in ❑no ❑n/a ❑no ❑Na
If double walled sump, is ❑yes ❑yes ❑yes ❑yes ❑yes
interstitial space free of liquid? ❑no ❑Na ❑no ❑n/a ❑no ❑n1a ❑no ❑n/a ❑no ❑n/a
Results of sump Inspection O pass O pass 13 pass O pass 13 pass
0 fail O fail 0 fail O fail 0 fail
Hand Held Release Detection Equipment Inspection
❑gauge stick ❑gauge stick ❑gauge stick ❑gauge stick ❑gauge stick
Type of hand held release ❑groundwater ❑groundwater ❑groundwater ❑groundwater ❑groundwater
detection equipment bailer bailer bailer bailer bailer
❑other(specify): ❑other(specify): ❑other(specify): ❑other(specify):
s ec' : ❑other(specify):
Results of equipment O pass E3 pass O pass E3 pass O pass
Inspection 0 fall O fall 0 fall O fall 0 fall
Repairs Needed Date of Repair Description of any Repairs
Inspector's Signature:
ADEM Form 19 3111 m2(revised 8/19)