Form ECY070-69 "Leak Testing Checklist for Underground Storage Tanks (Usts)" - Washington

What Is Form ECY070-69?

This is a legal form that was released by the Washington State Department of Ecology - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2020;
  • The latest edition provided by the Washington State Department of Ecology;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form ECY070-69 by clicking the link below or browse more documents and templates provided by the Washington State Department of Ecology.

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Download Form ECY070-69 "Leak Testing Checklist for Underground Storage Tanks (Usts)" - Washington

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UST ID #: __________
L
T
C
EAK
ESTING
HECKLIST
County: __________
U
S
T
(UST
)
FOR
NDERGROUND
TORAGE
ANKS
S
This checklist certifies testing activities conducted in accordance with
Chapter 173-360A WAC. Read instructions on pages 4-7.
PASS –
All Section VI services performed have passing results.
D
T
C
:
/ /
ATE
ESTS
ONDUCTED
FAIL –
One or more components tested in Section VI require repair
and re-testing.
I. UST F
II. C
S
P
ACILITY
ERTIFIED
ERVICE
ROVIDER
Facility Compliance Tag #: A ____
Service Provider Name:
UST ID #:
Company Name:
Site Name:
Address:
Site Address:
City:
State:
Zip:
City:
Phone:
Email:
County:
ICC Certification Type:
Site Phone:
ICC Cert. #:
Exp. Date:
III. UST O
/O
WNER
PERATOR
Name:
Phone:
Email:
IV. UST S
I
YSTEM
NFORMATION
O
bservations on test day.
1. Tank ID #,
as registered with Ecology or identified on ATG
2. Tank Status.
OP (Operational); TC (Temporary Closure)
3. Product stored,
including % of alternative fuels
4. Tank or compartment capacity
(gallons)
5. Product pumping/flow method.
Note as: P (Pressurized); NS (Non-safe
Suction); SS (Safe Suction); Si (Siphon); GR (Gravity Fed)
Abbreviations for lines 6 and 7 below:
Steel (ST); Fiberglass (FRP); Clad Steel (CLAD); Flexible (FLEX); Double Wall (DW); Single Wall (SW); Not Visible (NV)
6. Tank material and construction observed
7. Pipe material and construction observed
V. R
S
P
EASON FOR
ERVICES
ERFORMED
(Check all that apply)
Annual testing
Test after install/repair
Other (explain):
3-year testing
Return UST system to operation
1
ECY 070-69 (Rev. May 2020)
UST ID #: __________
L
T
C
EAK
ESTING
HECKLIST
County: __________
U
S
T
(UST
)
FOR
NDERGROUND
TORAGE
ANKS
S
This checklist certifies testing activities conducted in accordance with
Chapter 173-360A WAC. Read instructions on pages 4-7.
PASS –
All Section VI services performed have passing results.
D
T
C
:
/ /
ATE
ESTS
ONDUCTED
FAIL –
One or more components tested in Section VI require repair
and re-testing.
I. UST F
II. C
S
P
ACILITY
ERTIFIED
ERVICE
ROVIDER
Facility Compliance Tag #: A ____
Service Provider Name:
UST ID #:
Company Name:
Site Name:
Address:
Site Address:
City:
State:
Zip:
City:
Phone:
Email:
County:
ICC Certification Type:
Site Phone:
ICC Cert. #:
Exp. Date:
III. UST O
/O
WNER
PERATOR
Name:
Phone:
Email:
IV. UST S
I
YSTEM
NFORMATION
O
bservations on test day.
1. Tank ID #,
as registered with Ecology or identified on ATG
2. Tank Status.
OP (Operational); TC (Temporary Closure)
3. Product stored,
including % of alternative fuels
4. Tank or compartment capacity
(gallons)
5. Product pumping/flow method.
Note as: P (Pressurized); NS (Non-safe
Suction); SS (Safe Suction); Si (Siphon); GR (Gravity Fed)
Abbreviations for lines 6 and 7 below:
Steel (ST); Fiberglass (FRP); Clad Steel (CLAD); Flexible (FLEX); Double Wall (DW); Single Wall (SW); Not Visible (NV)
6. Tank material and construction observed
7. Pipe material and construction observed
V. R
S
P
EASON FOR
ERVICES
ERFORMED
(Check all that apply)
Annual testing
Test after install/repair
Other (explain):
3-year testing
Return UST system to operation
1
ECY 070-69 (Rev. May 2020)
VI. S
P
ERVICES
ERFORMED
Required: Include verification for each test performed.
#
REPAIRED
#
#
PASS
FAIL
& PASSING
S
:
D
: (
. 4-7)
ERVICES
ESCRIPTIONS REQUIRED
SEE INSTRUCTIONS P
ALLD Test
(attach data)
Test method used:
Test method cert. exp. date:
Line Tightness Test
(attach data)
Test method used:
Test method cert. exp. date:
Electronic Monitoring System Tests
Controller manufacturer/model
Controller cert. exp. date
Monitor/controller
Probe
Sump Sensor Functionality
Tank Annular Sensor Functionality
Auto shutoff
Overfill Equipment
Test
Ball float valve
Overfill alarm
Fill/Spill Bucket Test (attach data)
Tank-Top or Transition Sump Test
(attach data)
UDC Sump Test (attach data)
Tank Tightness Test
(attach data)
3
rd
-party certified test:
Test method used:
Test method cert. exp. date:
Other
VII. E
/P
E
:
XPLANATIONS
ROBLEMS
NCOUNTERED
Provide additional test information. Explain irregularities. Describe problems encountered and how addressed.
2
ECY 070-69 (Rev. May 2020)
VIII. UST S
S
D
ITE AND
YSTEM
IAGRAM
Diagram required. Include North arrow.
P
ERSONS SUBMITTING FALSE INFORMATION ARE SUBJECT TO FORMAL ENFORCEMENT
/
C
173-360A WAC.
AND
OR PENALTIES UNDER
HAPTER
IX. F
C
INAL
HECK
Mark the following:
/
YES
NO
N
A
1. All checked services tested per recommended practices, code and/or manufacturer’s
requirements, and in accordance with state regulations.
2. Owner/operator provided with copy of the checklist and testing results.
3. Any faulty equipment or necessary repairs explained to owner/operator or site contact.
X. R
S
EQUIRED
IGNATURES
Date
Signature of Certified Service Provider
Print or Type Name
Date
Signature of Tank Owner or Authorized Representative
Print or Type Name
3
ECY 070-69 (Rev. May 2020)
L
T
C
EAK
ESTING
HECKLIST
I
NSTRUCTIONS
Tank owner/operator:
1. Within 24 hours, report failed tests resulting in a suspected or confirmed release to the appropriate Ecology
regional office.
2. Submit signed checklist and supporting documentation to Ecology within 30 days of testing, using one of
the following methods. Do not include these instructions pages with your submittal
Upload PDF to TCP External
US Mail
Document Submittal (TEDS):
WA Department of Ecology
Use Secure Access Washington (SAW) account;
Underground Storage Tank (UST) Section
Add TEDS as a new service;
PO Box 47655
Contact (360) 407-7170 for more information.
Olympia, WA 98504-7600
Service providers:
1. Completion of this checklist is confirmation of services performed in accordance with Chapter 173-360A
WAC.
2. Refer to Table 920-1 in the UST regulation for a list of services and required certifications.
3. With the checklist, include the test data recorded. Include make and model number for all tanks, piping,
sensors, ATGs, ALLDs, overfill devices, and spill buckets, if they can be determined.
4. The service provider must be certified to operate the equipment used for testing.
Checklist sections:
I-III. UST Facility; Certified Service Provider; UST Owner/Operator: Provide the UST facility compliance tag# (small
license plate) and/or UST ID#; ICC-certified service provider information; and owner/operator information.
IV.
UST System Information: Provide site-specific information about tanks and piping only if visually verified
during the site visit. To report product stored, use products listed at dispensers. Do not use Ecology records
to complete this section.
Reasons Services Performed: Check appropriate box or explain if different.
V.
VI.
Services Performed: Check all that apply and detail the location and number of components tested, plus test
method used. Find an example of Section VI on page 7.
• ALLD: List the ALLD test method and service provider’s test method certification expiration date in the
space provided. If an electronic ALLD is tested, the tester must also document proof of certification on the
ATG or other controller. Attach the ALLD test data (including ALLD make/model) to this checklist. Verify
the ALLD is third-party certified for use with the particular piping run (volume, through-put, etc.).
Per the method specified, perform the test from the furthest/highest elevation point of each piping run. If
satellite dispensers are installed, perform the test on each entire piping run from the furthest satellite
dispenser. If the ALLD does not pass the function test when tested at the farthest point in the line, it is a
4
ECY 070-69 (Rev. May 2020)
failed test for that piping run, including if the main dispenser solenoid is blocking the satellite line. In the
comments, indicate the dispenser number where testing was conducted.
Line Tightness Test: In the space provided, note the test method and service provider’s certification
expiration date for that method.
If the piping run includes satellite lines, ensure the entire piping run is tested. Follow manufacturer testing
procedures, verify the test method is third-party certified for the piping run being tested, and indicate the
dispenser number.
Electronic Monitoring System Tests: Record the monitor make, model, and tester’s certification
expiration date for it. If the monitor/controller does not have tester certification by the manufacturer,
leave the expiration date blank. List how many of each component was tested (e.g. probes, sensors, etc.).
Test requires removing probe(s).
a)
Monitor/controller and probes - One-year compliance tests include verifying system
configuration/programming, operation of alarms, battery backup, probes, free residual buildup,
floats move freely, shafts free from damage, and cables free of kinks/breaks. Verify equipment is
third-party certified for use by the particular UST system (i.e. through-put, manifold) and that
components are compatible with the product stored. List the recommended practice or code
followed.
b)
Sump Sensor Functionality - (sump sensor, vacuum or pressure): Test sensors per
manufacturer specifications or list the Recommended Practice used. Verify sensors are
compatible with the product stored and monitoring system. Ensure sensors are upright and
placed in the lowest part of the sump. Note if sensors are not connected to a monitoring system.
c)
Tank Annular Sensor Functionality (i.e. annular sensor, brine): Test per manufacturer
instructions or list the recommended practice used. Verify the annular space does not contain
product or water and monitoring equipment is functional. Verify monitoring equipment is
compatible with the product stored and communicating with the controller.
Overfill Equipment Test: Ensure overfill prevention equipment is set to activate no higher than the
required level (i.e. 95% tank capacity for automatic shutoffs; 90% tank capacity for overfill alarms; and
90% or manufacturer specifications for ball floats). Verify alarm is audible when standing at fill ports.
Remove automatic shutoff and ball float devices to confirm functionality. If the ball float device does not
pass the test, it cannot be replaced; another functioning form of overfill prevention must be installed.
Remove probes to confirm functionality of exterior alarm/float communication at calculated height.
Verify conflicting equipment does not affect overfill device operability. Conflict examples: ball float device
may not function with suction pumps or coaxial fills; automatic shut-offs may not function with ball float
stem inside tank unless the automatic shut-off device is set lower than the ball float stem. If known,
include the overfill device make and model and list the recommended practice or code followed.
Fill/Spill Bucket Test: Include the make, model and whether spill bucket is single wall (SW) or double wall
(DW) construction. Note if a test fails due to visual observation only. DW spill buckets that have both
walls continuously monitored are exempt from every 3-year testing if inspected and documented
monthly. List the Recommended Practice or code followed.
Tank Top or Transition Sump Test: Required if relying on interstitially monitored piping, including any
piping run installed after October 1, 2012. Describe containment sump as SW or DW. If the piping run
includes transition sumps, enter those sump tests in this section. Note if a test fails due to visual
observation only. DW sumps that have both walls continuously monitored are exempt from every 3-year
testing if inspected and documented annually. List the recommended practice or code followed.
5
ECY 070-69 (Rev. May 2020)
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