Form ECY070-71 "Retrofit/Repair Checklist for Underground Storage Tank" - Washington

What Is Form ECY070-71?

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 October 1, 2018;
  • 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 ECY070-71 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 ECY070-71 "Retrofit/Repair Checklist for Underground Storage Tank" - Washington

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R
/R
C
ETROFIT
EPAIR
HECKLIST
U
S
T
FOR
NDERGROUND
TORAGE
ANKS
This checklist certifies that retrofit/repair activities were performed and conducted in accordance
with Chapter 173-360A WAC. Instructions are found on the back page.
I. UST F
II. ICC S
P
ACILITY
ERVICE
ROVIDER
Facility Compliance Tag #:
Service Provider Name:
UST ID #:
Company Name:
Site Name:
Address:
Site Address:
City:
State:
Zip:
City:
Phone:
(
)
-
Email:
County:
Certification Type:
Phone:
(
)
-
Certification Number:
Exp. Date:
III. UST O
/O
WNER
PERATOR
Name:
Phone:
(
)
-
Email:
Address:
City:
State:
Zip:
IV. UST S
I
YSTEM
NFORMATION
(use bolded names, where applicable)
Tank ID:
Tank ID:
Tank ID:
Tank ID:
1. Tank ID # (tank name registered with Ecology)
2. Date installed
3. Tank capacity in gallons
4. Tank material (specify for each tank):
Steel (ST); Steel Clad w/ Corrosion Resist (CLAD);
Fiberglass Reinforced Plastic (FRP); STIp3
5. Tank construction (specify for each tank):
Single wall (SW); double wall (DW); compartment (COMP)
6. Piping material (specify for each tank):
Steel (ST); Fiberglass Reinforced Plastic (FRP);
Flexible Plastic (FLEX); Other (specify):
7. Piping construction (specify for each tank):
Single wall (SW); Double wall (DW)
ECY 070-71 (Revised October 2018)
1
R
/R
C
ETROFIT
EPAIR
HECKLIST
U
S
T
FOR
NDERGROUND
TORAGE
ANKS
This checklist certifies that retrofit/repair activities were performed and conducted in accordance
with Chapter 173-360A WAC. Instructions are found on the back page.
I. UST F
II. ICC S
P
ACILITY
ERVICE
ROVIDER
Facility Compliance Tag #:
Service Provider Name:
UST ID #:
Company Name:
Site Name:
Address:
Site Address:
City:
State:
Zip:
City:
Phone:
(
)
-
Email:
County:
Certification Type:
Phone:
(
)
-
Certification Number:
Exp. Date:
III. UST O
/O
WNER
PERATOR
Name:
Phone:
(
)
-
Email:
Address:
City:
State:
Zip:
IV. UST S
I
YSTEM
NFORMATION
(use bolded names, where applicable)
Tank ID:
Tank ID:
Tank ID:
Tank ID:
1. Tank ID # (tank name registered with Ecology)
2. Date installed
3. Tank capacity in gallons
4. Tank material (specify for each tank):
Steel (ST); Steel Clad w/ Corrosion Resist (CLAD);
Fiberglass Reinforced Plastic (FRP); STIp3
5. Tank construction (specify for each tank):
Single wall (SW); double wall (DW); compartment (COMP)
6. Piping material (specify for each tank):
Steel (ST); Fiberglass Reinforced Plastic (FRP);
Flexible Plastic (FLEX); Other (specify):
7. Piping construction (specify for each tank):
Single wall (SW); Double wall (DW)
ECY 070-71 (Revised October 2018)
1
V. TANK
R
/R
I
ETROFIT
EPAIR
NFORMATION
(circle
or
for each job completed)
INSTALL
REPAIR
R
D
Tank ID:
Tank ID:
Tank ID:
Tank ID:
ELEASE
ETECTION
1. Install / Repair of release detection equipment (specify):
Automatic tank gauge (ATG); Probe; Interstitial monitor (IM);
Interstitial sensor (IS); Other (specify):
C
P
ORROSION
ROTECTION
1. Install / Repair internal lining
2. Install / Repair impressed current rectifier
3. Addition of supplementary anodes
4. Addition of boots to metal flex connectors
5. Other repair (specify):
S
/O
P
E
PILL
VERFILL
REVENTION
QUIPMENT
1. Install / Repair spill bucket
2. Install / Repair of overfill prevention device (specify):
Auto Shutoff (AUTO); Overfill Alarm (ALM); Ball Float Valve (BFV)
O
R
THER
EPAIR
1. Install / Repair containment sump
2. Install / Repair (specify):
Turbine Pump (TP); Riser Pipe (RP); Tank Structure (TS)
Other (specify):
Other Repair not Listed
and/or Additional
Comments:
VI. PIPING
Retrofit/Repair Information
(circle INSTALL or REPAIR for each job completed)
R
D
Tank ID:
Tank ID:
Tank ID:
Tank ID:
ELEASE
ETECTION
1. Install / Repair release detection equipment (specify):
Sump Sensor (SUMP); Automatic Line Leak Detector (ALLD);
Other (specify):
O
R
THER
EPAIR
1. Install / Repair under dispenser containment (UDC)
2. Repair piping (<50% of piping run) (specify):
ST
FRP
FLEX
Other (specify):
3. Replacement of piping (>50% of piping run, must install DW)
(specify):
ST
FRP
FLEX
Other (specify):
Other Repair not Listed
and/or Additional
Comments:
ECY 070-71 (Revised October 2018)
2
VII. C
HECKLIST
The following items shall be initialed by the Certified Supervisor whose
YES
NO
N/A
signature appears below.
1. Have all items checked above been installed, repaired, or replaced per code
and manufacturer’s requirements and in accordance with federal and/or state
regulations?
2. Has the owner/operator been provided with written documentation of the
item(s) installed, repaired or replaced?
Date work was completed:
VIII. S
IGNATURES
I hereby attest, that I have been the Certified Supervisor present on site during the above listed
retrofitting/repair activities, and to the best of my knowledge they have been conducted in compliance with
all applicable state and federal laws, regulations and procedures, pertaining to underground storage tanks.
P
/
ERSONS SUBMITTING FALSE INFORMATION ARE SUBJECT TO FORMAL ENFORCEMENT AND
OR
C
173-360A WAC.
PENALTIES UNDER
HAPTER
Date
Signature of ICC Certified Provider
Print or Type Name
Date
Signature of UST Owner/Operator
Print or Type Name
ECY 070-71 (Revised October 2018)
3
I
NSTRUCTIONS
R
/R
C
ETROFIT
EPAIR
HECKLIST
U
S
T
FOR
NDERGROUND
TORAGE
ANKS
I
NSTRUCTIONS
 This Underground Storage Tank (UST) checklist is required for retrofit and repair activities on regulated
USTs. Completing this checklist documents and certifies the activities are performed and conducted in
accordance with Chapter 173-360A WAC.
 This checklist must be filled out completely by an International Code Council (ICC) certified provider for
Installation and Retrofits of USTs within 30 days following the completion of the retrofit and repair activity.
 A copy of the completed form must be provided to the tank system owner/operator.
 The owner/operator is responsible for submitting a copy of the completed checklist to Ecology within 30
days of completing the activity.
I.
UST Facility: Complete this section about the UST facility and use the Facility Compliance Tag #
(License Plate) and/or UST ID # (if known) to help identify the location.
II.
ICC Certified Provider: Complete this section about the ICC certified supervisor and service provider
company.
III.
UST Owner/Operator: Complete this section about the owner or operator of the UST facility.
IV.
System Information: This section should be completed based on field observations. Use the bolded
abbreviations, where applicable.
V.
Tank Retrofit/Repair Information: Complete all sections that apply. If work performed is not listed,
complete “Other” and provide additional information in Comments section. Use the bolded
abbreviations, where applicable.
VI.
Piping Retrofit/Repair Information: Complete all sections that apply. If work performed is not listed,
complete “Other” and provide additional information in Comments section. Use the bolded
abbreviations, where applicable.
VII.
Checklist: Initial in the appropriate box to answer the questions.
VIII.
Signatures: The ICC Service Provider must sign and date the completed form.
Mail Checklist to:
Department of Ecology
Underground Storage Tank Section
PO Box 47655
Olympia, WA 98504-7600
If you need this document in a format for the visually impaired call the Toxics Cleanup Program at 360-407-7170.
Persons with hearing loss, call 711 for Washington Relay Service. Persons with a speech disability, call 877-833-6341.
ECY 070-71 (Revised October 2018)
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