Form 2630-FM-BECB0501 "Underground Storage Tank Facility Operations Inspection Report Form" - Pennsylvania

What Is Form 2630-FM-BECB0501?

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Form Details:

  • Released on March 1, 2019;
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2630-FM-BECB0501
Rev. 3/2019
Form
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF ENVIRONMENTAL CLEANUP AND BROWNFIELDS
UNDERGROUND STORAGE TANK FACILITY
FOR DEP USE ONLY
Reviewer________ Date________
OPERATIONS INSPECTION REPORT FORM
Entered by_______Date________
FACILITY INFORMATION
CERTIFIED INSPECTOR
ID Number
Name
_________________________________________
Name
______________________________________
ID No.
__________________________________________
Location
______________________________________
Phone
_________________________________________
Address
______________________________________
E-mail
_________________________________________
Date of First Site Visit (month/day/year)
Municipality
__________________________________
_______________________________________________
GPS Location
Lat:
Long:
_________
TANK OWNER (must be a person or an entity)
Representative Present During Inspection
Name
______________________________________
Name
_________________________________________
TANK OPERATOR (if different than owner)
Phone
_________________________________________
Name
______________________________________
Owner
Operator
Employee
None
Suspected or confirmed contamination observed
Yes
(notify proper region within 48 hours) No
Improperly closed or unregistered tanks present
Yes
(provide comment)
No
Fire/safety permit(s) available (if required)
Yes
No
N/A
Fire/Safety Permit Number(s)
Issued By
Amended registration form required for (check all that apply):
Added tanks
Closed tanks
Change of operational status (in or out of service)
Change in substance stored
Change of owner
Change in tank size
Inspection summary.
Indicate the compliance status of each item below using the following codes: N = Noncompliant; C = Compliant. Note: Yes, No, *, N/A,
blanks, or any other markings are not acceptable statements for these fields.
Tank No.
Tank No.
Tank No.
Tank No.
Tank No.
Registration Certificate Display
Tank Release Detection
Tank Release Detection Testing
Piping Release Detection
Piping Release Detection Testing
Overfill Prevention
Overfill Prevention Testing
Spill Prevention
Spill Prevention Testing
Financial Responsibility
Walkthrough Inspections
Tank Construction and Corrosion Protection
Piping Construction and Corrosion Protection
Operator Training
I, the DEP Certified Inspector (IUM), have inspected the entire above referenced facility including examining manways, sumps, monitoring wells
and dispensers. Based on my personal observation of the facility and documentation provided by the owner, I certify under penalty of law as
provided in 18 PA C.S.A. Section 4904 (relating to unsworn falsification to authorities), that the information provided by me is true, accurate
and complete to the best of my knowledge and belief.
Certified Inspector’s Signature
Date
As the representative of the owner or operator, I have reviewed the completed inspection report. I certify under penalty of law as provided in
18 PA C.S.A. Section 4904 (relating to unsworn falsification to authorities), that the information provided by me is true, accurate and complete
to the best of my knowledge and belief.
Signature
Title
Date
Page 1
2630-FM-BECB0501
Rev. 3/2019
Form
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF ENVIRONMENTAL CLEANUP AND BROWNFIELDS
UNDERGROUND STORAGE TANK FACILITY
FOR DEP USE ONLY
Reviewer________ Date________
OPERATIONS INSPECTION REPORT FORM
Entered by_______Date________
FACILITY INFORMATION
CERTIFIED INSPECTOR
ID Number
Name
_________________________________________
Name
______________________________________
ID No.
__________________________________________
Location
______________________________________
Phone
_________________________________________
Address
______________________________________
E-mail
_________________________________________
Date of First Site Visit (month/day/year)
Municipality
__________________________________
_______________________________________________
GPS Location
Lat:
Long:
_________
TANK OWNER (must be a person or an entity)
Representative Present During Inspection
Name
______________________________________
Name
_________________________________________
TANK OPERATOR (if different than owner)
Phone
_________________________________________
Name
______________________________________
Owner
Operator
Employee
None
Suspected or confirmed contamination observed
Yes
(notify proper region within 48 hours) No
Improperly closed or unregistered tanks present
Yes
(provide comment)
No
Fire/safety permit(s) available (if required)
Yes
No
N/A
Fire/Safety Permit Number(s)
Issued By
Amended registration form required for (check all that apply):
Added tanks
Closed tanks
Change of operational status (in or out of service)
Change in substance stored
Change of owner
Change in tank size
Inspection summary.
Indicate the compliance status of each item below using the following codes: N = Noncompliant; C = Compliant. Note: Yes, No, *, N/A,
blanks, or any other markings are not acceptable statements for these fields.
Tank No.
Tank No.
Tank No.
Tank No.
Tank No.
Registration Certificate Display
Tank Release Detection
Tank Release Detection Testing
Piping Release Detection
Piping Release Detection Testing
Overfill Prevention
Overfill Prevention Testing
Spill Prevention
Spill Prevention Testing
Financial Responsibility
Walkthrough Inspections
Tank Construction and Corrosion Protection
Piping Construction and Corrosion Protection
Operator Training
I, the DEP Certified Inspector (IUM), have inspected the entire above referenced facility including examining manways, sumps, monitoring wells
and dispensers. Based on my personal observation of the facility and documentation provided by the owner, I certify under penalty of law as
provided in 18 PA C.S.A. Section 4904 (relating to unsworn falsification to authorities), that the information provided by me is true, accurate
and complete to the best of my knowledge and belief.
Certified Inspector’s Signature
Date
As the representative of the owner or operator, I have reviewed the completed inspection report. I certify under penalty of law as provided in
18 PA C.S.A. Section 4904 (relating to unsworn falsification to authorities), that the information provided by me is true, accurate and complete
to the best of my knowledge and belief.
Signature
Title
Date
Page 1
2630-FM-BECB0501
Rev. 3/2019
Form
UNDERGROUND STORAGE TANK FACILITY
OPERATIONS INSPECTION REPORT FORM
Facility Name
Date
Facility ID
I. TANK SYSTEM INFORMATION. For each tank, fill in the required information using the codes on Page 2-1. Where multiple codes are allowed and
used for a specific tank component, describe the arrangement in Section VIII (COMMENTS). (See FOI form instructions for details.)
Tank No.
Tank No.
Tank No.
Tank No.
Tank No.
1.
Tank capacity (name plate gallons)
2.
Substance currently stored (and grade)
3.
Installation date (M/d/yyyy)
4.
This drone tank is manifolded to tank number
5a.
Stick reading of product level, in inches, at time of inspection
5b.
Stick reading of water level, in inches, at time of inspection
6.
Total secondary containment on this tank system
1, 3
7.
Tank construction and corrosion protection
1, 2
8a.
Primary (inner or single-wall) piping construction
1, 2
8b.
Secondary (outer) piping construction
4
9a.
Number of tank top sumps
4
9b.
Number of tank top sumps tested tight
10a. Number of transition sumps
10b. Number of transition sumps tested tight
11a. Number of connected dispensers
11b. Number of connected dispensers with pans
11c. Number of dispenser pans tested tight
12a. Piping joints/connections construction at tank
1, 6
12b. Piping joints/connections construction at dispenser
1, 6
13.
Pump (product dispensing) system
14a. Number of spill containments (must be permanently installed)
14b. Number of spill containments tested tight
15.
Overfill type (must be permanently installed)
16.
Current registration certificate displayed/readily available
17.
Stage I vapor recovery
18.
Stage II vapor recovery
19.
This tank supplies an emergency generator
20.
Tank release detection
21.
Piping small release detection (0.2 gph monthly or 0.1 gph
annually)
22.
Pressure (line 13 is C or D) piping line leak detector (LLD
Function - 3 gph at 10 lbs psi or equivalent within 1 hr)
5
23.
LLD function includes a positive turbine pump shutoff
1
Use of codes indicating a component is Unknown should be accompanied with comments in Section VIII and must be marked Noncompliant for the appropriate tank
system compliance status in the Inspection summary on Page 1.
2
indicate manufacturer, model, and generation (if applicable) in Section VIII.
3
indicate manufacturer and construction in Section VIII.
4
at tank penetrations that have pipe that routinely contains or conveys product.
5
LLD function must include positive turbine shutoff for piping systems installed after 11/10/2007 with pressurized piping systems.
6
Use of code (X – None) or (99 – Other) should include comments in Section VIII.
Site drawing / manifold schematic (not master-drone system):
Page 2
2630-FM-BECB0501
Rev. 3/2019
Form
UNDERGROUND STORAGE TANK FACILITY
OPERATIONS INSPECTION REPORT FORM
Tank System Component Codes
6. Total secondary containment
12. Piping joints/connections
19. This tank supplies an emergency
Y Yes
A Unprotected metallic
generator
N No
component(s) (including only
Y
Yes
wrapped or coated)
N
No
7. Tank construction
B Cathodically protected, metallic
20. Tank release detection
A Single-wall steel, unprotected
F Unknown (must provide written
D
Statistical Inventory
B Single-wall, galvanic anodes
comment)
Reconciliation (SIR)
C Impressed current protection
I
Completely inside a
E
Certified Automatic Tank
E Single-wall fiberglass (FRP)
containment sump
Gauge (0.2 gph Leak Test)
F Double-wall fiberglass (FRP)
M Completely jacketed with
F
Manual Tank Gauging (36
G Double-wall Act 100 or
sealed boot
Hour), no TTT
equivalent
N NO jacket, not in contact with
G44 Manual Tank Gauging,
H Single-wall Act 100 or equivalent
the ground
44 Hours
I
Steel with lined interior
X None (must provide written
G58 Manual Tank Gauging,
J Concrete
comment)
58 Hours
O Double-wall, steel primary,
99 Other (must provide written
H
Interstitial Monitoring (2
galvanic anodes
comment)
Walls)
P Cathodically protected and lined
J
Groundwater Monitoring
V Double-wall Act 100 or
13. Pump (delivery) system
K
Vapor Monitoring
equivalent with Anodes
A Suction, check valve at pump or
N
None
W Single-wall Act 100 or equivalent
siphon bar only
21. Piping small release detection
with Anodes
B Suction, check valve at tank
(0.2/0.1 gph)
N Unknown (must provide written
C Pressure
B
Annual Line Tightness Test
comment)
D Gravity flow to dispenser/pump
(pressure)
99 Other (must provide written
E None
C
Line Tightness Test - 3 years
comment)
15. Overfill type (if code S or B, ensure
(suction)
8a. Primary (inner or single-wall) piping
compatible with delivery method)
D
Monthly Interstitial
construction
S Drop tube shut off device
Monitoring (includes visual
A Bare steel (including only
A Overfill alarm (provide
checking)
wrapped or coated)
description and location in
E
Groundwater Monitoring
B Cathodically protected, metallic
comment section)
F
Vapor Monitoring
C Copper, unprotected
B Ball float valve
H
None
D Fiberglass or rigid non-metallic
E Filled in less than 25 gallon
I
Exempt (must provide written
E Flexible non-metallic
increments
comment)
F Unknown (must provide written
N None present or not usable
J
Statistical Inventory
comment)
16. Current registration certificate
Reconciliation (SIR)
G No dispensing piping
display
K
Electronic Line Leak Detector
I
Stainless Steel
Y Properly displayed - manned
(0.1 or 0.2 gph test)
99 Other (must provide written
R Readily available - unmanned
22. Piping line leak detection (3 gph
comment)
N Not displayed
within 1 hr.)
8b. Secondary (outer)piping
17. Stage I vapor recovery
A
Mechanical Line Leak
construction
A Coaxial
Detector
N None (Single-walled piping)
B 2 port
H
None
A Bare steel
N Not complete or none
K
Electronic Line Leak Detector
B Cathodically protected, metallic
18. Stage II vapor recovery
(3 gph test)
D Fiberglass or rigid non-metallic
A Complete balance system
L
Continuous Interstitial
E Flexible non-metallic
B Complete assist system
Monitoring with alarm or
F Unknown (must provide written
C UG piping only; not complete
pump shut off
comment)
D Decommissioned
23. Positive Turbine pump shutoff
G No dispensing piping
N None of the above
Y
Yes
I
Poly-encased Stainless Steel
N
Not present
99 Other (must provide written
comment)
Page 2-1
2630-FM-BECB0501
Rev. 3/2019
Form
UNDERGROUND STORAGE TANK FACILITY
OPERATIONS INSPECTION REPORT FORM
Facility Name
Date
Facility ID
II. RELEASE DETECTION
Instructions:
Check the box to indicate that a criterion has been met.
Circle the box to indicate that a criterion has not been met.
Circle with “N/A” when a criterion is not applicable (provide comment).
Release Detection Recordkeeping:
Records may be located at the facility or a readily available alternate site.
The records include all of the information listed below for chosen release detection methods.
The inspector has personally reviewed the records.
If the facility is missing release detection records or if the facility has invalid and/or failing
records, enter the dates and results in Section VIII.
A test with an inconclusive result or failure is an indication of a (suspected) product release and
must be investigated within 7 days. Enter the results of any suspected release investigations in
Section VIII.
An empty tank (no more than 1” of product and/or sludge) that is properly registered as
Tank
Tank
Tank
Tank
Tank
temporarily out-of-use is not required to perform release detection. Indicate date emptied in
System
System
System
System
System
comments.
Recently installed tank systems must begin performing release detection immediately after
receiving product. Indicate date of first product receipt in comments.
Tank Release Detection Recordkeeping:
tank release detection records for the last 12 months the system contained product are available
tank release detection records are all valid and passing
tank release detection records with invalid or failing reports were properly investigated and
documented within 7 days, to confirm or disconfirm the occurrence of a release
written certifications or performance claims for the tank release detection method(s) in use are
available
written documentation of all calibration, maintenance and repair of tank release detection
equipment for the last year is available
all tank release detection equipment is compatible with the substance stored
Tank Release Detection Equipment Testing:
electronic and mechanical components of tank release detection equipment tested within the
last year and documentation available
tester name:
tester certification number:
date of last test:
result:
Piping Release Detection Recordkeeping:
piping release detection records for the last 12 months the system contained product are
available
piping release detection records are all valid and passing
piping release detection records with invalid or failing reports were properly investigated and
documented within 7 days, to confirm or disconfirm the occurrence of a release
written certifications or performance claims for the piping release detection method(s) in use are
available
written documentation of all calibration, maintenance and repair of piping release detection
equipment for the last year is available
all piping release detection equipment is compatible with the substance stored
Piping Release Detection Equipment Testing:
electronic and mechanical components of piping release detection equipment tested within the
last year and documentation available
tester name:
tester certification number:
date of last test:
result:
Page 3
2630-FM-BECB0501
Rev. 3/2019
Form
UNDERGROUND STORAGE TANK FACILITY
OPERATIONS INSPECTION REPORT FORM
Facility Name
Date
Facility ID
II. RELEASE DETECTION (continued)
Instructions:
Check the box to indicate that a criterion has been met.
Circle the box to indicate that a criterion has not been met.
Circle with “N/A” when a criterion is not applicable (provide comment).
Release Detection Equipment (Tank and/or Piping):
The inspector has personally reviewed the tank release detection equipment in use for each tank
Tank
Tank
Tank
Tank
Tank
System
System
System
System
System
system.
Automatic Tank Gauging: (Tank only – code E)
ATG manufacturer:
ATG model:
Does the automatic tank gauge perform continuous in-tank release detection?
Yes
No
probes and gauge software certified for manifolded tank systems
 when not specifically certified, the siphon must be broken to properly test
equipment is operational
Manual Tank Gauging: (Tank only – code F, G44 or G58)
tank capacity is 1,000 gallons or less
tank installed on or before 11/10/2007
performed weekly
1/8th inch accuracy stick readings
average 2 stick readings before and after test
test length appropriate for each tank
36 hours minimum
44 hours, 551-1000 gallons, 64” diameter
58 hours, 551-1000 gallons, 48” diameter
variation is within standard (both weekly and monthly)
Interstitial Monitoring: (Tank code H; describe monitoring equipment in comments)
interstitial sensors properly placed (per manufacturer’s instructions)
monitoring wells (secondary barrier) or ports are clearly marked and secured
Statistical Inventory Reconciliation: (Tank code D and/or Piping code J)
test vendor:
version:
data is collected according to the test vendor’s instructions
analysis complete and valid results supplied to owner/operator within 30 day monitoring period
valid reports include calculated leak rate, minimum detectible leak rate, leak threshold,
probability of detection and probability of false alarm
Groundwater or Vapor Monitoring: (Tank code J or K and/or Piping code E or F; describe well locations and monitoring equipment in
comments)
wells are located according to site evaluation; attach page with properly licensed evaluator
authentication to the inspection report
wells are properly installed in accordance with site evaluation and regulations
monitoring wells are marked and secured
fill material is sufficiently porous to allow expeditious detection at the monitoring wells
substance stored meets regulatory requirements for type of monitoring
Groundwater monitoring: (Tank code J and/or Piping code E)
monitoring devices can detect 1/8 inch of product or less on water
groundwater is within 20 feet of surface grade
wells are sealed from ground surface to the top of the filter pack
casing is properly slotted: allows entry of product during all groundwater conditions
Vapor Monitoring: (Tank code K and/or Piping code F)
the monitoring device is not rendered inoperative by moisture
background contamination will not interfere with vapor monitoring
vapor monitors will detect increases in concentrations of stored substance
Page 4
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