Form UST-6E (UST-23D) "Application to Install or Replace Underground Storage Tank Systems (Tank Installation/Triennial Testing)" - North Carolina

What Is Form UST-6E (UST-23D)?

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

Form Details:

  • Released on May 1, 2021;
  • The latest edition provided by the North Carolina Department of Environmental Quality;
  • 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 fillable version of Form UST-6E (UST-23D) by clicking the link below or browse more documents and templates provided by the North Carolina Department of Environmental Quality.

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Download Form UST-6E (UST-23D) "Application to Install or Replace Underground Storage Tank Systems (Tank Installation/Triennial Testing)" - North Carolina

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Application to Install or Replace Underground Storage Tank Systems
UST-6E/23D
(TANK INSTALLATION/TRIENNIAL TESTING)
A separate form should be used for each facility. If there are more than five (5) tanks at this facility, make additional copies of this page.
The primary and interstitial space of the tank shall be tested in accordance with the manufacturers written guidelines and PEI/RP100 “Recommended Practice
for Installation of Underground Liquid Storage Systems.”
The last periodic tightness test record must be maintained by the tank owner or operator and must be readily available for inspection.
Tanks that are not monitored continuously for releases using vacuum, pressure, or hydrostatic methods must be tightness tested at installation, between 6 and
12 months from installation, and every three years following installation.
rd
The interstitial space of the tank shall be tested using a 3
party certified interstice tightness test capable of detecting a 0.1 gph leak from the inner or outer wall
of the interstice for the tank model that is installed.
If the tank fails a tightness test, it must be replaced or repaired by the manufacturer or the manufacturer’s authorized representative in accordance with the
manufacturer’s specifications. Following any repair, the tank must be re-tested for tightness. Also a suspected release report must be submitted on a UST-17A
form, UST Suspected Release 24 Hour Notice. The suspected release must be investigated, in accordance with 15A NCAC 2N .0603, and any defective
equipment repaired/replaced in accordance with 15A NCAC 2N .0404/.0900. Results of the investigation must be submitted on a UST-17B form, UST Suspected
Release 7 Day Notice.
UST FACILITY
Owner / Operator Name
Facility Name
Facility ID#:
Facility Street Address
Facility City
County
Yancey
TESTING CONTRACTOR INFORMATION
Company Name
Phone
E-mail address
Mailing Address
City
State
Zip
WY
Print Name of person conducting test
Signature of person conducting test
Identify Tank (Tank Number, etc.)
Tank #
Tank #
Tank #
Tank #
Tank #
Tank Size
Product
UST Type
(FRP, Steel Jacketed, Steel/CLAD,
Other)
I. Pre-installation testing
Vacuum/Pressure Gauge Range (indicate units):
Interstitial space - Liquid Filled or Vacuum
Test method:
Vacuum
Liquid filled/other:
Test Date
Begin ị End Test Time
Begin ị End Level (liquid)
(Indicate units)
Begin ị End Pressure/Vacuum
(Indicate units)
Liquid visible on inside/outside
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
of tank (if applicable)
Test Result
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Tightness Test Model (if applicable):
II. Post-installation/triennial testing
Vacuum/Pressure Gauge Range (indicate units):
Interstitial space - Liquid Filled/Other.
Test method:
Vacuum
Liquid filled/other:
Test Date: Begin ị End
Begin ị End Test Time
Begin ị End Level (liquid)
(Indicate units)
Begin ị End Pressure/Vacuum
(Indicate units)
Liquid visible on inside of tank
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Manufacturer test data sheets
attached (e.g., Xerxes Truchek,
Yes
N/A
Yes
N/A
Yes
N/A
Yes
N/A
Yes
N/A
CSI Standpipe Test)
Test Result
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Comments:
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY, DIVISION OF WASTE MANAGEMENT, UST SECTION
1646 MAIL SERVICE CENTER, RALEIGH, NC 27699-1646 PHONE (919) 707-8171 FAX (919) 715-1117 http://www.wastenotnc.org 5/2021
Application to Install or Replace Underground Storage Tank Systems
UST-6E/23D
(TANK INSTALLATION/TRIENNIAL TESTING)
A separate form should be used for each facility. If there are more than five (5) tanks at this facility, make additional copies of this page.
The primary and interstitial space of the tank shall be tested in accordance with the manufacturers written guidelines and PEI/RP100 “Recommended Practice
for Installation of Underground Liquid Storage Systems.”
The last periodic tightness test record must be maintained by the tank owner or operator and must be readily available for inspection.
Tanks that are not monitored continuously for releases using vacuum, pressure, or hydrostatic methods must be tightness tested at installation, between 6 and
12 months from installation, and every three years following installation.
rd
The interstitial space of the tank shall be tested using a 3
party certified interstice tightness test capable of detecting a 0.1 gph leak from the inner or outer wall
of the interstice for the tank model that is installed.
If the tank fails a tightness test, it must be replaced or repaired by the manufacturer or the manufacturer’s authorized representative in accordance with the
manufacturer’s specifications. Following any repair, the tank must be re-tested for tightness. Also a suspected release report must be submitted on a UST-17A
form, UST Suspected Release 24 Hour Notice. The suspected release must be investigated, in accordance with 15A NCAC 2N .0603, and any defective
equipment repaired/replaced in accordance with 15A NCAC 2N .0404/.0900. Results of the investigation must be submitted on a UST-17B form, UST Suspected
Release 7 Day Notice.
UST FACILITY
Owner / Operator Name
Facility Name
Facility ID#:
Facility Street Address
Facility City
County
Yancey
TESTING CONTRACTOR INFORMATION
Company Name
Phone
E-mail address
Mailing Address
City
State
Zip
WY
Print Name of person conducting test
Signature of person conducting test
Identify Tank (Tank Number, etc.)
Tank #
Tank #
Tank #
Tank #
Tank #
Tank Size
Product
UST Type
(FRP, Steel Jacketed, Steel/CLAD,
Other)
I. Pre-installation testing
Vacuum/Pressure Gauge Range (indicate units):
Interstitial space - Liquid Filled or Vacuum
Test method:
Vacuum
Liquid filled/other:
Test Date
Begin ị End Test Time
Begin ị End Level (liquid)
(Indicate units)
Begin ị End Pressure/Vacuum
(Indicate units)
Liquid visible on inside/outside
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
of tank (if applicable)
Test Result
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Tightness Test Model (if applicable):
II. Post-installation/triennial testing
Vacuum/Pressure Gauge Range (indicate units):
Interstitial space - Liquid Filled/Other.
Test method:
Vacuum
Liquid filled/other:
Test Date: Begin ị End
Begin ị End Test Time
Begin ị End Level (liquid)
(Indicate units)
Begin ị End Pressure/Vacuum
(Indicate units)
Liquid visible on inside of tank
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Manufacturer test data sheets
attached (e.g., Xerxes Truchek,
Yes
N/A
Yes
N/A
Yes
N/A
Yes
N/A
Yes
N/A
CSI Standpipe Test)
Test Result
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Pass
Fail
Comments:
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY, DIVISION OF WASTE MANAGEMENT, UST SECTION
1646 MAIL SERVICE CENTER, RALEIGH, NC 27699-1646 PHONE (919) 707-8171 FAX (919) 715-1117 http://www.wastenotnc.org 5/2021