ADEM Form 19 "Annual Walkthrough Inspection Checklist Log" - Alabama

This version of the form is not currently in use and is provided for reference only.
Download this version of ADEM Form 19 for the current year.

What Is ADEM Form 19?

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

Form Details:

  • Released on August 1, 2019;
  • The latest edition provided by the Alabama Department of Environmental Management;
  • 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 ADEM Form 19 by clicking the link below or browse more documents and templates provided by the Alabama Department of Environmental Management.

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Download ADEM Form 19 "Annual Walkthrough Inspection Checklist Log" - Alabama

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_____Fac #_____ANWALK_____Date_____
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 # or
Dispenser #
Product Stored
Is the Site Using Interstitial Leak
 yes
 no
 yes
 no
 yes
 no
 yes
 no
 yes
 no
Detection for Piping?
Visual Containment Sump Inspection
 sub pump
 sub pump
 sub pump
 sub pump
 sub pump
Type of containment sump
 intermediate
 intermediate
 intermediate
 intermediate
 intermediate
inspected
 dispenser
 dispenser
 dispenser
 dispenser
 dispenser
 yes
 yes
 yes
 yes
 yes
Is the sump an earthen sump?
 no
 no
 no
 no
 no
 yes
 yes
 yes
 yes
 yes
Is the visible piping in good
 no
 no
 no
 no
 no
condition?
 yes
 yes
 yes
 yes
 yes
Is there evidence of a release?
 no
 no
 no
 no
 no
(If release found, report it to ADEM)
 yes
 yes
 yes
 yes
 yes
Is the Sump free of damage?
 no
 n/a
 no
 n/a
 no
 n/a
 no
 n/a
 no
 n/a
 yes
 yes
 yes
 yes
 yes
Is the Sump free of water, fuel,
 no
 n/a
 no
 n/a
 no
 n/a
 no
 n/a
 no
 n/a
and/or debris?
 yes
 yes
 yes
 yes
 yes
Water, fuel and/or debris removed
 no
 n/a
 no
 n/a
 no
 n/a
 no
 n/a
 no
 n/a
and disposed of properly?
 yes
 yes
 yes
 yes
 yes
Are penetrations (boots, conduits,
 no
 n/a
 no
 n/a
 no
 n/a
 no
 n/a
 no
 n/a
etc.) into sump in good condition?
Is primary piping interstitial space
 yes
 yes
 yes
 yes
 yes
open, or test boots positioned, to
 no
 n/a
 no
 n/a
 no
 n/a
 no
 n/a
 no
 n/a
allow product to enter sump?
 yes
 yes
 yes
 yes
 yes
Are the sensors properly positioned
 no
 n/a
 no
 n/a
 no
 n/a
 no
 n/a
 no
 n/a
near bottom of sump?
 yes
 yes
 yes
 yes
 yes
If double walled sump, is
 no
 n/a
 no
 n/a
 no
 n/a
 no
 n/a
 no
 n/a
interstitial space free of liquid?
 pass
 pass
 pass
 pass
 pass
Results of sump inspection
 fail
 fail
 fail
 fail
 fail
Hand Held Release Detection Equipment Inspection
 gauge stick
 gauge stick
 gauge stick
 gauge stick
 gauge stick
 groundwater
 groundwater
 groundwater
 groundwater
 groundwater
Type of hand held release
detection equipment
bailer
bailer
bailer
bailer
bailer
 other (specify):
 other (specify):
 other (specify):
 other (specify):
 other (specify):
 pass
 pass
 pass
 pass
 pass
Results of equipment
 fail
 fail
 fail
 fail
 fail
inspection
Repairs Needed
Date of Repair
Description of any Repairs
Inspector’s Signature:
ADEM Form 19 3/11 m2 (revised 8/19)
_____Fac #_____ANWALK_____Date_____
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 # or
Dispenser #
Product Stored
Is the Site Using Interstitial Leak
 yes
 no
 yes
 no
 yes
 no
 yes
 no
 yes
 no
Detection for Piping?
Visual Containment Sump Inspection
 sub pump
 sub pump
 sub pump
 sub pump
 sub pump
Type of containment sump
 intermediate
 intermediate
 intermediate
 intermediate
 intermediate
inspected
 dispenser
 dispenser
 dispenser
 dispenser
 dispenser
 yes
 yes
 yes
 yes
 yes
Is the sump an earthen sump?
 no
 no
 no
 no
 no
 yes
 yes
 yes
 yes
 yes
Is the visible piping in good
 no
 no
 no
 no
 no
condition?
 yes
 yes
 yes
 yes
 yes
Is there evidence of a release?
 no
 no
 no
 no
 no
(If release found, report it to ADEM)
 yes
 yes
 yes
 yes
 yes
Is the Sump free of damage?
 no
 n/a
 no
 n/a
 no
 n/a
 no
 n/a
 no
 n/a
 yes
 yes
 yes
 yes
 yes
Is the Sump free of water, fuel,
 no
 n/a
 no
 n/a
 no
 n/a
 no
 n/a
 no
 n/a
and/or debris?
 yes
 yes
 yes
 yes
 yes
Water, fuel and/or debris removed
 no
 n/a
 no
 n/a
 no
 n/a
 no
 n/a
 no
 n/a
and disposed of properly?
 yes
 yes
 yes
 yes
 yes
Are penetrations (boots, conduits,
 no
 n/a
 no
 n/a
 no
 n/a
 no
 n/a
 no
 n/a
etc.) into sump in good condition?
Is primary piping interstitial space
 yes
 yes
 yes
 yes
 yes
open, or test boots positioned, to
 no
 n/a
 no
 n/a
 no
 n/a
 no
 n/a
 no
 n/a
allow product to enter sump?
 yes
 yes
 yes
 yes
 yes
Are the sensors properly positioned
 no
 n/a
 no
 n/a
 no
 n/a
 no
 n/a
 no
 n/a
near bottom of sump?
 yes
 yes
 yes
 yes
 yes
If double walled sump, is
 no
 n/a
 no
 n/a
 no
 n/a
 no
 n/a
 no
 n/a
interstitial space free of liquid?
 pass
 pass
 pass
 pass
 pass
Results of sump inspection
 fail
 fail
 fail
 fail
 fail
Hand Held Release Detection Equipment Inspection
 gauge stick
 gauge stick
 gauge stick
 gauge stick
 gauge stick
 groundwater
 groundwater
 groundwater
 groundwater
 groundwater
Type of hand held release
detection equipment
bailer
bailer
bailer
bailer
bailer
 other (specify):
 other (specify):
 other (specify):
 other (specify):
 other (specify):
 pass
 pass
 pass
 pass
 pass
Results of equipment
 fail
 fail
 fail
 fail
 fail
inspection
Repairs Needed
Date of Repair
Description of any Repairs
Inspector’s Signature:
ADEM Form 19 3/11 m2 (revised 8/19)