CONTRACTOR S SELF-INSPECTION CHECKLIST for UST INSTALLATION REPLACEMENT UPGRADE RETROFIT REPAIR

Transcription

1 Environmental Health - UST Program CONTRACTOR S SELF-INSPECTION CHECKLIST for UST INSTALLATION REPLACEMENT UPGRADE RETROFIT REPAIR As part of our inter-local contract with the Nevada Division of Environmental Protection, SNHD - Environmental Health UST Program requires this document be signed by Nevada Certified UST Handler and be submitted to us during our final inspection for compliance with U.S. EPA Federal Code 40 CFR TECHNICAL STANDARDS AND CORRECTIVE ACTION FOR OWNERS AND OPERATORS OF UNDERGROUND STORAGE TANKS USTs). This checklist does not preclude any testing requirements set up by other regulatory agencies e.g., Air Quality, Fire Department, etc.), nationally recognized codes e.g., PEI, API, NACE, etc.) or the component manufacturers e.g., Veeder-Root, FE Petro, etc.). Facility Name: PH: Facility Address: include City, State & Zip) Owner Name: PH: Owner Mailing Address: include City, State & Zip) Contractor Name: PH: Contractor Mailing Address: include City, State & Zip) UST Handler Name: PH: UST Handler Address: include City, State & Zip) Tank Tester Name: PH: Certification Number: Expiration Date: Tank Tester Address include City, State & Zip) PLEASE CHECK THE FOLLOWING THAT APPLY: New UST Installation Number of Tanks Tank Replacement Number of Tanks Piping Replacement Dispenser Replacement Leak Containment Sump Dispensers Leak Containment Sump Turbines Tank Gauge & Monitor Replacement UST System Upgrade for US EPA 1998 requirements for Corrosion, Spill, Overfill, Leak Detection) Summarize work to be done: UST Equipment Retrofit Summarize work to be done: UST System Repair Summarize work to be done: UST PROGRAM: 702) FAX: 702) P. O. Box 3902 ~ Las Vegas, Nevada ~ 702) ~

2 CERTIFICATION STATEMENT I certify that all work performed on this UST system meets manufacturer's specifications and all devices installed meet federal performance requirements. I further agree to hold the District harmless from all claims, defense and legal cost, judgments for damages, or other relief against the District as a result of acts of omissions, by me or my representatives, in the performance of any activities permitted hereunder, whether the condition giving rise to the claim or judgment was created in whole, or in part, by me or my representative. The foregoing statement is true to the best of my knowledge. SIGNATURE: UST Handler) Please Print Name) DATE Certification No./Exp. Date) Company Name) ************************************************************************************************************************************************************ PETROLEUM ENVIRONMENTAL CONTAMINATION STATEMENT I certify that during the construction, upgrade, retro-fit or repair of this UST system that: Please check the appropriate statement) No petroleum environmental contamination was encountered; or Petroleum environmental contamination less than the Nevada Reportable Quantities and less than the UST Soil Action Level was encountered and effectively remediated; or Petroleum environmental contamination above the Nevada Reportable Quantities and/or the UST Action Level, was encountered and appropriately reported to the Nevada Division of Environmental Protection and Southern Nevada Health District - Environmental Health - UST Program. Corrective Action is in progress or completed. SIGNATURE: UST Handler/CEM) Please Print Name) DATE Nevada Certification No.) Expiration Date) Nevada Division of Environmental Protection NDEP) Water Pollution Control has regulations NAC 445A.347 and 40 CFR 302) for reporting spills of certain substances once the quantity has exceeded certain limits. For Petroleum, the reportable quantity is greater than 25 gallons or three cubic yards of petroleum contaminated soil. 40 CFR 280 Subpart E - Release Reporting, Investigation, and Confirmation requires that spills less than 25 gallons be clean-up within 24 hours or otherwise be reported to the implementing agency. For petroleum spills greater than 25 gallons, the code requires reporting within 24 hours and corrective action in accordance with 40 CFR 280-Subpart F - Release Response and Corrective Action for UST Systems... NAC Compliance with Federal Regulations mandates that UST owners and operators comply with the requirements of 40 CFR 280 Subpart E and F). The NDEP Underground Storage Tank Regulations NAC ) identifies the presence of petroleum in soil in excess of 100 milligrams per kilogram measured by using laboratory analytical method 8015 modified for petroleum hydrocarbons) as the soil action level. If the soil exceeds the soil action level, NDEP may require the UST owner or operator to take corrective action. SNHD does not oversee leaking UST corrective action and defers all decisions for corrective action to NDEP. SNHD does send a letter to inform the UST owner/operator to follow the requirements of 40 CFR 280 Subpart E and F and contact NDEP for further guidance when petroleum contamination in soil has exceeded the soil action level. If petroleum or petroleum additives are suspected to have contaminated ground water, the UST owner or operator shall install at least one monitoring well NAC ).

3 NEW UST INSTALLATION CHECKLIST Page 1 U.S. EPA Form , Notification of Underground Storage Tanks, must be submitted to SNHD ) within 30 days of bringing the UST into use. This form, in turn will be forwarded to the Nevada Division of Environmental Protection - UST Petroleum Claims Office as application for the Nevada Petroleum Fund - Spill/Release Clean-up Reimbursement Insurance. UST owners and operators must comply with the Financial Responsibility requirements of the U.S. EPA UST Code 40 CFR Subpart H for cleaning up spills and leaks and for compensating third party injury and property damage. All tanks and piping must be properly installed in accordance with a code of practice developed by a nationally recognized association e.g., American Petroleum Institute, Petroleum Equipment Institute, etc.); independent laboratory e.g., Underwriter Laboratories); or the manufacturer s instructions e.g., XERXES). Please identify Code:, Laboratory:, or Manufacturer s Name: used for this UST System installation. Please complete all of the NEW UST INSTALLATION CHECKLIST by circling YES or NO as appropriate. Please fill in all blanks with the requested information. PEI/RP Recommended Practices for Installation of Underground Liquid Storage Systems Introduction - Chapter 1 Section reviewed & followed Material Handling - Chapter 2 Section reviewed & followed Excavating - Chapter 3 Section reviewed & followed Backfilling - Chapter 4 Section reviewed & followed Supports & Anchorage - Chapter 5 Section reviewed & followed Spill Containment & Overfill Prevention - Chapter 6 Section reviewed & followed Secondary Containment - Chapter 7 Section reviewed & followed Release Detection - Chapter 8 Section reviewed & followed Piping, Valves & Fittings - Chapter 9 Section reviewed & followed Cathodic Protection Systems - Chapter 10 Section reviewed & followed Electrical Installation - Chapter 11 Section reviewed & followed Testing - Chapter 12 Section reviewed & followed Documentation & Training - Chapter 13 Section reviewed & followed Float-out & Anchorage Calculation - Appendix A Section reviewed & followed Background: Cathodic Protection - Appendix B Section reviewed & followed SAFETY Site Safety Plan available Site personnel reviewed plan Potential Hazards Identified Potential Hazards Abated Personal Protective Equipment Available Fire Extinguishers available Spill Kit available Absorbent material available Combustible gas meter available Oxygen deficiency meter available Personnel OSHA trained TANKSU.S. EPA Code Corrosion Control requirements) Tank Manufacturer: Number of tanks being installed: Identify all tanks that are manifolded together Single walled Tank # Double walled Tank # Tank #1 gallons product Tank#2 gallons product Tank #3 gallons product Tank#4 gallons product Tank #5 gallons product Tank#6 gallons product Tank #7 gallons product Tank#8 gallons product Corrosion Protection check all that apply): Tank # Tanks made of a non-corrosive material e.g., fiberglass) Steel tank coated with or enclosed in) non-corrosive material e.g., epoxy) Steel tanks coated with non-corrosive material & has cathodic protection e.g., STI/P3) Un-coated steel tanks with cathodic protection e.g., impressed current) Un-coated steel tanks with interior lined with non-corrosive material Un-coated steel tanks with interior lining & cathodic protection

4 NEW UST INSTALLATION CHECKLIST - Page 2 PIPINGU.S. EPA Code Corrosion Control requirements) Piping Manufacturer: Single walled Tank # Double walled Tank # Pressurized Tank # Suction Tank # Corrosion Protection Check all that apply) Piping made of non-corrosive material Un-coated metal piping & flex lines not in direct contact with soil Booting for un-coated metal piping & flex lines taping is unacceptable) Impressed Current Cathodic Protection for un-coated metal piping Galvanic sacrificial anode) protection for un-coated metal piping If Impressed Current or galvanic corrosion systems are used, the following is required: 1. Diagram of system with equipment list e.g., rectifier, anodes, packing, wiring, test stations, etc.) 2. Corrosion survey/site assessment results 3. Name of nationally recognized code or independent laboratory used for design 4. Name of designer corrosion expert), credentials, company, address & phone 5. Name of system tester, credentials, company, address & phone If interior lining is provided, the following is required: 1. Name of nationally recognized code or independent laboratory used for design 2. Name of designer coatings expert), credentials, company, address & phone) 3. Interior inspection/survey results TANK LEAK DETECTION SYSTEM Automatic Tank Gauge Manufacturer Circle leak check method) 0.2 gph CSLD Annular SIR Inv Ctr Manual Gauging Monitor accessible & protected from damage Printer OK Manifolded Tank Tank capacity < 15,000 gal Double-walled tank monitoring a.k.a. interstitial or annular) Sensors properly installed Portal is leak tight Sensor Type Manufacturer: Sensor is compatible with Tank Monitor Audible & Visual Alarm Monitor is accessible & protected form damage Alarm in close proximity Groundwater or Soil Vapor monitoring installed Manufacturer: Site assessment conducted 40 CFR e)&f) criteria met PIPING LEAK DETECTION Product piping runs less than 75 ft. Proper Slope Large elevation changes e.g. Marinas, Building, etc) Solenoids Major topographical changes Single wall piping Tightness Test conducted Nevada Certified Tank Tester used Pressurized piping Line Leak Detector Mechanical or Electric Electric LLD Vapor or Pressure Auto 3gph Test monitor available Circle tests conducted) 0.1gph 0.2gph 3gph Suction piping Proper Slope YES/N Check All metal components corrosion resistant or adequately protected Was Cathodic Protection system used Operational survey report rec d Class I Ignitable Gases & Vapors) National Electrical Code requirements followed Electrician s Name: Credentials: Company: PH: Address:_

5 NEW UST INSTALLATION CHECKLIST - Page 3 PIPING LEAK DETECTION continued) Double-walled piping Continuously leak monitored Initial & Annual tightness test required Tightness Test conducted Nevada Certified Tank Tester used Leak Turbine Leak tested sump Method: Sumps are protected from outside rain or wash water Water Tight Riser Lid Water tight sump surface) Leak Dispenser Leak Tested Sump Method: Sumps are protected from outside rain or wash water Curbs or dikes provided Leak Turbine Sump Leak Disp. Sump Leak Sensor Type: Manufacturer: Sensor Tested Audible & Visual Alarm Piping slopes to turbine sump Piping drains to turbine leak sensor Pressurized Piping Line leak detector Electric or Mechanical mechanical receives annual test) Electric LLD Vapor or Pressure Auto 3gph Test monitor available Circle tests conducted) 0.1gph 0.2gph 3gph Suction piping Proper Slope Check All components corrosion resistant or adequately protected Was Cathodic Protection system used Operational survey report received Class I Ignitable Gases & Vapors) National Electrical Code requirements followed Electrician s Name: Credentials: Company: PH: Address: FILL TUBE SPILL CATCHMENT BASIN SPILL BUCKET) - Installed into riser sump from tank Fill Tube Catchment Basin capacity gallons Manufacturer: Leak tested basin Method: Sumps are protected from outside rain or wash water Water Tight Lid Raised concrete, curbing or diking Basin sealed to grade Flexible assembly Drain or Pump Installed Operational Overfill will not contaminate soil Labeled to alert fuel delivery of overfill device Fill tube locked OVERFILL PREVENTION DEVICE ref. 40 CFR c)) Check all that are installed & operational Auto Shut Off Device Type e.g., flapper): Manufacturer: Manufacturer s instructions followed Appropriate chart used for distance below tank inches Tank Diameter inches Gravity fill Float operates properly No obstructions in fill tube Operationally tested Shuts capacity Signs or labels posted to notify delivery person Air tight fill connection Ball Float with vapor recovery system Extractable for maintenance Manufacturer: Manufacturer s instructions followed Appropriate chart used for distance below tank inches Tank Diameter inches Operationally tested Air escapes from other opening of tanke.g. tank gauge) Ball cage intact Ball moves freely Ball seals tightly to air opening Air hole open Restricts 90% capacity or Restricts flow 30 minutes before overfill Suction Piping or other air eliminators installed) Pressurized Delivery Coaxial Stage 1 Vapor Recovery Remote fill Gauge openings Emergency Power Generator UST Air tight fill connection Signs or labels posted to notify delivery person of the type of overfill device Overfill Alarm Manufacturer Manufacturer s instructions followed Operationally tested Alerts at 90% capacity or 1 minute before overfill Alarm can be heard and seen by delivery person Tank Overfill Alarm sign posted Fill tube labeled to notify delivery person of the type of overfill device

6 NEW UST INSTALLATION CHECKLIST - Page 4 BOOTING installed on flex lines turbines off turbine under dispenser pans water tight both ends CATHODIC PROTECTION - ref. 40 CFR ,.21 &.30) Sacrificial galvanic) anodes On Tanks On Piping Anode Manufacturer: Material Size lbs. Est. life yrs. No. of Anodes Packaging Removed Anodes Wetted Adequate accessory materials e.g. wire) Wire gauge Adequate electrical welds or connections Type of weld or connector Adequate installation Test Stations installed Materials protected are electrically isolated from pump, vent, fill, conduit, etc. As-built diagram provided Nat l Code followed or Third Party Eval Identify Design Code or Third Party Designer: Credentials: Initial Operational Survey Conducted Nat l Code Test followed Qualified Tester Name: Credentials: Operational Survey Report provided Laboratory or Code Criteria Met Impressed Current For Tanks For piping Both tank & piping Rectifier Manufacturer: Accessible & Protected Amp/Volt Meter on Rectifier Amp/Volt Meter readings satisfactory Anode Manufacturer: Material Anode Packing Material Depth of Anode ft.no. of Anodes Installed As-built diagram provided Nat l Code followed or Third Party Eval Identify Design Code or Third Party Designer: Credentials: Initial Operational Survey Conducted Laboratory or Nat l Code Test followed Qualified Tester: Credentials: Operational survey report provided Laboratory or Code Criteria Met TANK LINING ref. 40 CFR ) No. of Tanks Lined Contents Rec d Design Specifications Lining Material Designer: Credentials: Lining material compatible with gasoline compatible w/ additives Internal coating inspected Inspection Report Rec d Inspection Criteria Used Passed Criteria Coating Inspector: Credentials: TANK REPAIRS ref. 40 CFR ) Tank repaired Tank Manufacturer: Tightness Test Required Conducted Report Received Monthly Tank Monitoring Method Internal Inspection Required Conducted Report Received Inspector: Credentials: Repairs conducted in accordance with: 1. Nationally Recognized Code Code Name: 2. Independent Testing Laboratory Name: Address Contact: PH: 3. Manufacturer s Representative Name: Address: PH:

7 EXISTING UST SYSTEM UPGRADE, RETROFIT, REPAIR, or REPLACEMENT - Page 1 U.S. EPA Form , Notification of Underground Storage Tanks UST), must be submitted to SNHD ) whenever construction, retrofit, replacement or address; or ownership), etc. effects a change in the original data maintained by the Nevada Division of Environmental Protection NDEP) - Petroleum Claims office. UST owners and operators must comply with the Financial Responsibility requirements of the U.S. EPA Code 40 CFR Subpart H for cleaning up spills and leaks and for compensating third arty injury and damage. All tanks and piping must be properly installed in accordance with a code of practice developed by a nationally recognized association e.g., American Petroleum Institute, Petroleum Equipment Institute, etc.); independent laboratory e.g., Underwriter Laboratories); or the manufacturer s instructions e.g., XERXES). Please identify Code:, Laboratory:, or Manufacturer s Name: used for this UST construction project. PEI/RP Recommended Practices for Installation of Underground Liquid Storage System Check appropriate PEI/RP sections used for this UST construction project and circle YES for verification: Introduction - Chapter 1 Section reviewed & followed Material Handling - Chapter 2 Section reviewed & followed Excavating - Chapter 3 Section reviewed & followed Backfilling - Chapter 4 Section reviewed & followed Supports & Anchorage - Chapter 5 Section reviewed & followed Spill Containment & Overfill Prevention - Chapter 6 Section reviewed & followed Secondary Containment - Chapter 7 Section reviewed & followed Release Detection - Chapter 8 Section reviewed & followed Piping, Valves & Fittings - Chapter 9 Section reviewed & followed Cathodic Protection Systems - Chapter 10 Section reviewed & followed Electrical Installation - Chapter 11 Section reviewed & followed Testing - Chapter 12 Section reviewed & followed Documentation & Training - Chapter 13 Section reviewed & followed Float-out & Anchorage Calculation - Appendix A Section reviewed & followed Background: Cathodic Protection - Appendix B Section reviewed & followed Please complete applicable checklists) by circling YES or NO as appropriate and provide information as requested. SAFETY Site Safety Plan available Site personnel reviewed plan Potential Hazards Identified Personal Protective Equipment Available Fire Extinguishers available Spill Kit available Absorbent material available Combustible gas meter available Oxygen deficiency meter available Personnel OSHA trained TANK REPAIRS ref. 40 CFR ) Tank Manufacturer: Tank # Material Size gal. Contents Tank # Material Size gal. Contents Tank # Material Size gal. Contents Tightness Test Required Conducted Report Received Monthly Tank Monitoring Method Internal Inspection Required Conducted Report Received Inspector: Credentials: Repairs conducted in accordance with: 1. Nationally Recognized Code Code Name: 2. Independent Testing Laboratory Name: Address Contact: PH: 3. Manufacturer s Representative Name: Address PH:

8 EXISTING UST SYSTEM UPGRADE, RETROFIT, REPAIR, or REPLACEMENT - Page 2 TANK LINING ref. 40 CFR ) Tank Manufacturer: Tank internally pre-inspected Pre-inspection Report Received Received Design Specifications Lining Material Designer: Credentials: Lining material compatible w/ gasoline w/ additives Internal coating inspected Inspection Report Received Inspection Criteria Used Passed Criteria Coating Inspector: Credentials: CATHODIC PROTECTION - ref. 40 CFR ,.21 &.30) Sacrificial galvanic) anodes On Tanks On Piping Both tanks and piping Anode Manufacturer: Material Size lbs.est. life yrs. No. of Anodes Packaging Removed Anodes Wetted Adequate accessory materials e.g. wire) Wire gauge Adequate electrical welds or connections Type of weld or connector Adequate installation Test Stations installed Materials protected are electrically isolated from pump, vent, fill, conduit, etc. As-built diagram provided Nat l Code followed or Third Party Eval Identify Design Code or Third Party Designer: Credentials: Initial Operational Survey Conducted Nat l Code Test followed Qualified Tester: Credentials: Operational Survey Report provided Laboratory or Code Criteria Met Impressed Current For Tanks For piping Both tank & piping Tank Assessment Required Received Passed laboratory or code criteria Laboratory or code criteria used for assessment Tank Inspector: Credentials: Rectifier Manufacturer: Accessible & Protected Amp/Volt Meter on Rectifier Amp/Volt Meter readings satisfactory Anode Manufacturer: Material Anode Packing Material Depth of Anode ft. No. of Anodes Installed As-built diagram provided Identify Design Code or Third Party Designer: Credentials: Initial Operational Survey Conducted Laboratory or Nat l Code Test followed Qualified Tester: Credentials: Operational survey report provided Laboratory or Code Criteria Met TANK LEAK DETECTION SYSTEM Automatic Tank Gauge installed/replaced-manufacturer: Circle leak check method) 0.2 gp CSLD Annular SIR Inv Ctr Manual Gauging Monitor accessible & protected from damage Printer OK Manifolded Tanks Tank capacity < 15,000 gal Double walled tank monitoring a.k.a. interstitial or annular) Sensors properly installed Portal is leak tight Sensor Type Manufacturer Sensor is compatible with Tank Monitor Audible & Visual Alarm Monitor is accessible & protected form damage Alarm in close proximity Groundwater or Soil Vapor monitoring installed Manufacturer: Site assessment conducted 40 CFR e)&f) criteria met

9 EXISTING UST SYSTEM UPGRADE, RETROFIT, REPAIR, or REPLACEMENT - Page 3 PIPING REPLACEMENT Product piping runs less than 75 ft. Proper Slope Large elevation changes e.g. Marinas, Building, etc) Solenoids Major topographical changes Single wall piping Tightness Test conducted Nevada Certified Tank Tester used Pressurized piping Line Leak Detector Mechanical or Electric Electric LD. Vapor or Pressure Auto 3gph Test monitor available Circle tests conducted) 0.1gph 0.2gph 3gph Suction Proper Slope Check All metal components corrosion resistant or adequately protected Was Cathodic Protection system used Operational survey report received Class I Ignitable Gases & Vapors) National Electrical Code requirements followed Double walled piping Continuously leak monitored or Initial & Annual tightness test required Tightness Test conducted Nevada Certified Tank Tester used Leak Turbine Leak tested sump Method Sumps are protected from outside rain or wash water Water Tight Riser Lid Water tight sump surface) Leak Dispenser Leak tested sump Method Sumps are protected from outside rain or wash water Curbs or dikes provided Leak Turbine Sump Leak Disp. Sump Leak Sensor Type Manufacturer Sensor Tested Audible & Visual Alarm Piping slopes to turbine sump Piping drains to turbine leak sensor Pressurized Piping Line leak detector Electric or Mechanical mechanical receives annual test) Electric LD. Vapor or Pressure Auto 3gph Test monitor available Circle tests conducted) 0.1gph 0.2gph 3gph Suction Proper Slope Check All components corrosion resistant or adequately protected Was Cathodic Protection system used Operational survey report received Class I Ignitable Gases & Vapors) National Electrical Code requirements followed Electrician s Name: Credentials: Company: PH: Address: FILL TUBE SPILL CATCHMENT BASIN SPILL BUCKET) Fill Tube Catchment Basin capacity gallons Manufacturer: Leak tested basin Method Sumps are protected from outside rain or wash water Water Tight Lid Raised concrete, curbing or diking Basin sealed to grade Flexible assembly Drain or Pump Installed Operational Overfill will not contaminate soil Labeled to alert fuel delivery of overfill device Installed into riser sump on tank OVERFILL PREVENTION DEVICE ref. 40 CFR c)) Check all that are installed and operational Auto Shut Off Device Typee.g,.flapper) Manufacturer: Mnfctr s instructions followed Appropriate chart used for distance below tank inches Tank Diameter inches Gravity fill Float operates properly No obstructions in fill tube Operationally tested Shuts capacity Signs or labels posted to notify delivery perso Air tight fill connection

10 EXISTING UST SYSTEM UPGRADE, RETROFIT, REPAIR, or REPLACEMENT - Page 4 OVERFILL PREVENTION DEVICE continued) Ball Float with vapor recovery system Extractable for maintenance Manufacturer: Mnfctr s instructions followed Appropriate chart used for distance below tank inches Tank Diameter inches Operationally tested Air escapes from other opening of tanke.g. tank gauge) Ball cage intact Ball moves freely Ball seals tightly to air opening Restricts 90% capacity or Restricts flow 30 minutes before overfill Suction Piping or other air eliminators installed) Pressurized Delivery Coaxial Stage 1 Vapor Recovery Remote fill Gauge openings Emergency Power Generator UST Air tight fill connection Signs or labels posted to notify delivery person of the type of overfill device Overfill Alarm Manufacturer: Mnfctr s instructions followed Operationally tested Probe operating properly Alerts at 90% capacity or 1 minute before overfill Alarm can be heard and seen by delivery person Tank Overfill Alarm sign posted Fill tube labeled to notify delivery person of the type of overfill device BOOTING installed on flex lines turbines off turbine under dispenser pans water tight both ends LEAK CONTAINMENT SUMP INSTALLATION Turbine Sump Manufacturer: Leak tested sump Leak test method Sumps are protected from outside rain or wash water Tight Lid Single walled piping Double-walled piping Piping Tightness Test Required Piping tightness test received Nevada Certified Tank Tester Name: Piping continuously leak monitored Leak sensors in sump Leak Sensor Type Manufacturer: Sensor Tested /NA Audible & Visual Alarm /NA Piping slopes to turbine sump Piping drains to leak sensor /NA All components corrosion resistant or adequately protected Was Cathodic Protection system effected Re-survey report received Qualified Cathodic Tester used Line leak detector Mechanical or Electric mechanical receives annual test) Electric LD. Vapor or Pressure Prints monitor Auto Shut off Class I Ignitable Gases & Vapors) National Electrical Code requirements followed Electrician s Name: Credentials: Address: Dispenser Sump Manufacturer: Leak tested sump Leak test method Leak Sensor Type Manufacturer: Sensor Tested /NA Audible & Visual Alarm /NA Sump drains to double wall piping Dispensers on Curbs All components corrosion resistant or adequately protected Was Cathodic Protection system effected Re-survey report received Qualified Cathodic Tester used Class I Ignitable Gases & Vapors) National Electrical Code requirements followed Electrician s Name: Credentials: Address: