**Vermont DEC Gas Station ERP Inspector Checklist\
**VT Agency of Natural Resources, Department of Environmental
Conservation, Waste Management Division

103 South Main St., Waterbury, VT 05671-0404.

Telephone: 802-241-3888

Fax: 802-241-3296

# I. Facility Information

<table style="width:100%;">
<colgroup>
<col style="width: 4%" />
<col style="width: 8%" />
<col style="width: 6%" />
<col style="width: 9%" />
<col style="width: 5%" />
<col style="width: 11%" />
<col style="width: 12%" />
<col style="width: 7%" />
<col style="width: 10%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 6%" />
<col style="width: 10%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="14"><em><strong>A. Facility Information</strong></em></td>
</tr>
<tr class="even">
<td colspan="4"><strong>1. Facility Name</strong></td>
<td colspan="2"><strong>2. Facility ID</strong></td>
<td colspan="3"><strong>3. Facility Physical Street
Address</strong></td>
<td colspan="5"><strong>4. Town/City</strong></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="5"></td>
</tr>
<tr class="even">
<td colspan="2"><strong>5. Zip Code</strong></td>
<td colspan="4"><strong>6. Facility GPS Location</strong></td>
<td colspan="2"><strong>7. Inspector</strong></td>
<td colspan="3"><strong>8. Date</strong></td>
<td colspan="2"><strong>9. Time In</strong></td>
<td><strong>10. Time Out</strong></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="5"><strong>11. Who is Tank Permittee?</strong></td>
<td colspan="9"><strong>12. Does the Facility Have Multiple Tank
Owners?</strong></td>
</tr>
<tr class="odd">
<td colspan="5"> Owner  Operator</td>
<td colspan="9"> Y  N A separate checklist is to be filled out for
each permittee at a facility.</td>
</tr>
<tr class="even">
<td colspan="14"><em><strong>B. Tank Owner
Information</strong></em></td>
</tr>
<tr class="odd">
<td colspan="4"><strong>1. Tank Owner</strong></td>
<td colspan="3"><strong>2. Owner Street Address (Mail)</strong></td>
<td colspan="5"><strong>3. Town/City</strong></td>
<td colspan="2"><strong>4. State</strong></td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="3"></td>
<td colspan="5"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>5. Zip Code</strong></td>
<td colspan="3"><strong>6. Tank Owner Tel</strong></td>
<td colspan="8"><strong>7. Tank Owner Contact Person
(Corp.)</strong></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="8"></td>
</tr>
<tr class="odd">
<td colspan="14"><em><strong>C. Property Owner
Information</strong></em></td>
</tr>
<tr class="even">
<td colspan="4"><strong>1. Property Owner</strong></td>
<td colspan="3"><strong>2. Prop. Owner Street Address
(Mail)</strong></td>
<td colspan="5"><strong>3. Town/City</strong></td>
<td colspan="2"><strong>4. State</strong></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="3"></td>
<td colspan="5"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="3"><strong>5. Zip Code</strong></td>
<td colspan="3"><strong>6. Property Owner Tel</strong></td>
<td colspan="8"><strong>7. Property Owner Contact Person
(Corp.)</strong></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="8"></td>
</tr>
<tr class="even">
<td colspan="14"><em><strong>D. Tank Operator
Information</strong></em></td>
</tr>
<tr class="odd">
<td colspan="4"><strong>1. Tank Operator</strong></td>
<td colspan="3"><strong>2. Operator Street Address (Mail)</strong></td>
<td colspan="5"><strong>3. Town/City</strong></td>
<td colspan="2"><strong>4. State</strong></td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="3"></td>
<td colspan="5"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>5. Zip Code.</strong></td>
<td colspan="3"><strong>6. Tank Operator Tel.</strong></td>
<td colspan="8"><strong>7. Onsite Representative</strong></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="8"></td>
</tr>
<tr class="odd">
<td><em><strong>E.</strong></em></td>
<td colspan="13"><p id="tank-information" class="heading">Tank
Information</p></td>
</tr>
<tr class="even">
<td>1</td>
<td colspan="9">Total number of permitted tanks <em>(note additional
non-permitted tanks in section G.1)</em></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td>2</td>
<td colspan="9">Does the facility have a UST permit?</td>
<td colspan="4"> Y  N</td>
</tr>
<tr class="even">
<td>3</td>
<td colspan="9">Is the current permit posted at the facility? <em>(*note
if previous permit posted)</em></td>
<td colspan="4"> Y  N</td>
</tr>
<tr class="odd">
<td>4</td>
<td colspan="9">Permit expiration date?</td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td>5</td>
<td colspan="9">Is the tank diagram posted?</td>
<td colspan="4"> Y  N</td>
</tr>
<tr class="odd">
<td>6</td>
<td colspan="9">Is the tank diagram accurate?</td>
<td colspan="4"> Y  N</td>
</tr>
<tr class="even">
<td>7</td>
<td colspan="9">Is the diagram visible from the tank pad?</td>
<td colspan="4"> Y  N</td>
</tr>
<tr class="odd">
<td>8</td>
<td colspan="9">Does the facility have a green sticker?</td>
<td colspan="4"> Y  N</td>
</tr>
<tr class="even">
<td>9</td>
<td colspan="9">Is the green sticker visible from the tank pad?</td>
<td colspan="4"> Y  N</td>
</tr>
<tr class="odd">
<td><em><strong>F.</strong></em></td>
<td colspan="13"><em><strong>Facility Information Section
Notes</strong></em></td>
</tr>
<tr class="even">
<td>1</td>
<td colspan="13">Notes:</td>
</tr>
</tbody>
</table>

# II. Underground Storage Tank System Profile

<table>
<colgroup>
<col style="width: 3%" />
<col style="width: 38%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 7%" />
</colgroup>
<tbody>
<tr class="odd">
<td><em><strong>A.</strong></em></td>
<td><em><strong>Status of Tank and Piping</strong></em></td>
<td colspan="2"><strong>Tank #1</strong></td>
<td colspan="2"><strong>Tank #2</strong></td>
<td colspan="2"><strong>Tank #3</strong></td>
<td colspan="2"><strong>Tank #4</strong></td>
</tr>
<tr class="even">
<td>1</td>
<td>Tank unique identifier</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>2</td>
<td>Is the tank currently in use?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td>3</td>
<td>Is the tank temporarily closed?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td>4</td>
<td><blockquote>
<p>If yes, what is the date of temporary closure?</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>5</td>
<td>Is the tank permitted?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td>6</td>
<td>When was the tank installed?</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>7</td>
<td>When was the piping installed?</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>8</td>
<td>Is the tank manifolded?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td>9</td>
<td><blockquote>
<p>To how many tanks is it manifolded?</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>10</td>
<td><blockquote>
<p>To which tank(s) is it manifolded?</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>11</td>
<td>Does the tank have more than one compartment?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td>12</td>
<td><blockquote>
<p>How many compartments does the overall tank have?</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>13</td>
<td><blockquote>
<p>Which other tanks are compartments of the same overall tank?</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>14</td>
<td>What is the tank capacity (in gallons)?</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>15</td>
<td>What is the product stored in the tank?</td>
<td><p> 2/4</p>
<p> 5/6</p>
<p> GS</p>
<p> DZ</p></td>
<td><p> KR</p>
<p> UO</p>
<p> CH</p>
<p> O</p></td>
<td><p> 2/4</p>
<p> 5/6</p>
<p> GS</p>
<p> DZ</p></td>
<td><p> KR</p>
<p> UO</p>
<p> CH</p>
<p> O</p></td>
<td><p> 2/4</p>
<p> 5/6</p>
<p> GS</p>
<p> DZ</p></td>
<td><p> KR</p>
<p> UO</p>
<p> CH</p>
<p> O</p></td>
<td><p> 2/4</p>
<p> 5/6</p>
<p> GS</p>
<p> DZ</p></td>
<td><p> KR</p>
<p> UO</p>
<p> CH</p>
<p> O</p></td>
</tr>
<tr class="odd">
<td>16</td>
<td><blockquote>
<p>If other, please specify:</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td><em><strong>B.</strong></em></td>
<td><em><strong>Tank Type</strong></em></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>1</td>
<td>Please specify the construction type for each tank. [Check all that
apply.]</td>
<td><p> SW</p>
<p> DW</p>
<p> P</p>
<p> PFRP</p>
<p> PFCS</p></td>
<td><p> PECS</p>
<p> PIC</p>
<p> PL</p>
<p> PLIC</p>
<p> O</p></td>
<td><p> SW</p>
<p> DW</p>
<p> P</p>
<p> PFRP</p>
<p> PFCS</p></td>
<td><p> PECS</p>
<p> PIC</p>
<p> PL</p>
<p> PLIC</p>
<p> O</p></td>
<td><p> SW</p>
<p> DW</p>
<p> P</p>
<p> PFRP</p>
<p> PFCS</p></td>
<td><p> PECS</p>
<p> PIC</p>
<p> PL</p>
<p> PLIC</p>
<p> O</p></td>
<td><p> SW</p>
<p> DW</p>
<p> P</p>
<p> PFRP</p>
<p> PFCS</p></td>
<td><p> PECS</p>
<p> PIC</p>
<p> PL</p>
<p> PLIC</p>
<p> O</p></td>
</tr>
<tr class="even">
<td>2</td>
<td><blockquote>
<p>If other, please specify:</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td><em><strong>C.</strong></em></td>
<td><em><strong>Piping Type</strong></em></td>
<td colspan="2"><strong>Tank #1</strong></td>
<td colspan="2"><strong>Tank #2</strong></td>
<td colspan="2"><strong>Tank #3</strong></td>
<td colspan="2"><strong>Tank #4</strong></td>
</tr>
<tr class="even">
<td>1</td>
<td>Please specify the construction type for each piping run. [Check all
that apply.]</td>
<td><blockquote>
<p>ABGD</p>
<p>NONE</p>
<p> PCC</p>
<p>PFLX</p>
<p>PFRP</p>
</blockquote></td>
<td><blockquote>
<p>PFTC</p>
<p>PIC</p>
<p>SW</p>
<p>DW</p>
<p>O</p>
</blockquote></td>
<td><blockquote>
<p>ABGD</p>
<p>NONE</p>
<p> PCC</p>
<p>PFLX</p>
<p>PFRP</p>
</blockquote></td>
<td><blockquote>
<p>PFTC</p>
<p>PIC</p>
<p>SW</p>
<p>DW</p>
<p>O</p>
</blockquote></td>
<td><blockquote>
<p>ABGD</p>
<p>NONE</p>
<p> PCC</p>
<p>PFLX</p>
<p>PFRP</p>
</blockquote></td>
<td><blockquote>
<p>PFTC</p>
<p>PIC</p>
<p>SW</p>
<p>DW</p>
<p>O</p>
</blockquote></td>
<td><blockquote>
<p>ABGD</p>
<p>NONE</p>
<p> PCC</p>
<p>PFLX</p>
<p>PFRP</p>
</blockquote></td>
<td><blockquote>
<p>PFTC</p>
<p>PIC</p>
<p>SW</p>
<p>DW</p>
<p>O</p>
</blockquote></td>
</tr>
<tr class="odd">
<td>2</td>
<td><blockquote>
<p>If other, please specify:</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>3</td>
<td>What is the product dispensing method?</td>
<td> S</td>
<td><p> P</p>
<p> O</p></td>
<td> S</td>
<td><p> P</p>
<p> O</p></td>
<td> S</td>
<td><p> P</p>
<p> O</p></td>
<td> S</td>
<td><p> P</p>
<p> O</p></td>
</tr>
<tr class="odd">
<td>4</td>
<td><blockquote>
<p>If other, please specify:</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td><em><strong>D.</strong></em></td>
<td><em><strong>Tank Repair History</strong></em></td>
<td colspan="2"><strong>Tank #1</strong></td>
<td colspan="2"><strong>Tank #2</strong></td>
<td colspan="2"><strong>Tank #3</strong></td>
<td colspan="2"><strong>Tank #4</strong></td>
</tr>
<tr class="odd">
<td>1</td>
<td>Has the tank ever been repaired?</td>
<td colspan="2"><blockquote>
<p> Y  N</p>
<p> Unk</p>
</blockquote></td>
<td colspan="2"><blockquote>
<p> Y  N</p>
<p> Unk</p>
</blockquote></td>
<td colspan="2"><blockquote>
<p> Y  N</p>
<p> Unk</p>
</blockquote></td>
<td colspan="2"><blockquote>
<p> Y  N</p>
<p> Unk</p>
</blockquote></td>
</tr>
<tr class="even">
<td>2</td>
<td><blockquote>
<p>Date tank was last repaired</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>3</td>
<td><blockquote>
<p>Was DEC notified of this repair?</p>
</blockquote></td>
<td colspan="2"><blockquote>
<p> Y  N</p>
</blockquote></td>
<td colspan="2"><blockquote>
<p> Y  N</p>
</blockquote></td>
<td colspan="2"><blockquote>
<p> Y  N</p>
</blockquote></td>
<td colspan="2"><blockquote>
<p> Y  N</p>
</blockquote></td>
</tr>
<tr class="even">
<td>4</td>
<td><blockquote>
<p>Specify what type of repair was performed</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td><em><strong>E.</strong></em></td>
<td><em><strong>Piping Repair History</strong></em></td>
<td colspan="2"><strong>Tank #1</strong></td>
<td colspan="2"><strong>Tank #2</strong></td>
<td colspan="2"><strong>Tank #3</strong></td>
<td colspan="2"><strong>Tank #4</strong></td>
</tr>
<tr class="even">
<td>1</td>
<td>Has the piping ever been repaired?</td>
<td colspan="2"><blockquote>
<p> Y  N</p>
<p> Unk</p>
</blockquote></td>
<td colspan="2"><blockquote>
<p> Y  N</p>
<p> Unk</p>
</blockquote></td>
<td colspan="2"><blockquote>
<p> Y  N</p>
<p> Unk</p>
</blockquote></td>
<td colspan="2"><blockquote>
<p> Y  N</p>
<p> Unk</p>
</blockquote></td>
</tr>
<tr class="odd">
<td>2</td>
<td><blockquote>
<p>Date piping was last repaired</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>3</td>
<td><blockquote>
<p>Was DEC notified of this repair?</p>
</blockquote></td>
<td colspan="2"><blockquote>
<p> Y  N</p>
</blockquote></td>
<td colspan="2"><blockquote>
<p> Y  N</p>
</blockquote></td>
<td colspan="2"><blockquote>
<p> Y  N</p>
</blockquote></td>
<td colspan="2"><blockquote>
<p> Y  N</p>
</blockquote></td>
</tr>
<tr class="odd">
<td>4</td>
<td><blockquote>
<p>Specify what type of repair was performed</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>5</td>
<td colspan="9">Notes:</td>
</tr>
</tbody>
</table>

# III. Temporarily Closed Tanks

+---+--------------------------------+-------+-------+-------+-------+
| * | ***Compliance for Temporarily  | *     | *     | *     | *     |
| * | Closed Tanks***                | *Tank | *Tank | *Tank | *Tank |
| * |                                | #1**  | #2**  | #3**  | #4**  |
| A | ***\[except corrosion          |       |       |       |       |
| . | protection, covered in other   |       |       |       |       |
| * | sections\]***                  |       |       |       |       |
| * |                                |       |       |       |       |
| * |                                |       |       |       |       |
+---+--------------------------------+-------+-------+-------+-------+
| 1 | Does the tank contain less     |  Y  |  Y  |  Y  |  Y  |
|   | than 1\" of product?           | N     | N     | N     | N     |
+---+--------------------------------+-------+-------+-------+-------+
| 2 | Are all other lines, pumps,    |  Y  |  Y  |  Y  |  Y  |
|   | manways and ancillary          | N     | N     | N     | N     |
|   | equipment secured?             |       |       |       |       |
+---+--------------------------------+-------+-------+-------+-------+
| 3 | Has the DEC been notified of   |  Y  |  Y  |  Y  |  Y  |
|   | the temporary closure?         | N     | N     | N     | N     |
+---+--------------------------------+-------+-------+-------+-------+
| 4 | Date tank was temporarily      |       |       |       | N     |
|   | closed                         |       |       |       |       |
+---+--------------------------------+-------+-------+-------+-------+
| 5 | Notes:                         |       |       |       |       |
+---+--------------------------------+-------+-------+-------+-------+

# 

# 

# 

#  IV. Tank Cathodic Protection

+---+--------------------------------+-------+-------+-------+-------+
| * | ***Sacrificial anodes***       | *     | *     | *     | *     |
| * |                                | *Tank | *Tank | *Tank | *Tank |
| * |                                | #1**  | #2**  | #3**  | #4**  |
| A |                                |       |       |       |       |
| * |                                |       |       |       |       |
| * |                                |       |       |       |       |
| * |                                |       |       |       |       |
+---+--------------------------------+-------+-------+-------+-------+
| 1 | Were sacrificial anodes        |  Y  |  Y  |  Y  |  Y  |
|   | factory-installed with the     | N     | N     | N     | N     |
|   | UST?                           |       |       |       |       |
+---+--------------------------------+-------+-------+-------+-------+
| 2 | Were supplemental anodes       |  Y  |  Y  |  Y  |  Y  |
|   | field-installed at a later     | N     | N     | N     | N     |
|   | date?                          |       |       |       |       |
|   |                                |  Unk |  Unk |  Unk |  Unk |
+---+--------------------------------+-------+-------+-------+-------+
| 3 | > When did the field           |       |       |       |       |
|   | > installation take place?     |       |       |       |       |
+---+--------------------------------+-------+-------+-------+-------+
| 4 | > Was installation completed   |  Y  |  Y  |  Y  |  Y  |
|   | > by a qualified professional? | N     | N     | N     | N     |
+---+--------------------------------+-------+-------+-------+-------+
| 5 | Was the protection system      |  Y  |  Y  |  Y  |  Y  |
|   | tested within the last 3       | N     | N     | N     | N     |
|   | years?                         |       |       |       |       |
|   |                                |  NR  |  NR  |  NR  |  NR  |
|   |                                |  RR  |  RR  |  RR  |  RR  |
+---+--------------------------------+-------+-------+-------+-------+
| 6 | > When was the most recent     |       |       |       |       |
|   | > test?                        |       |       |       |       |
+---+--------------------------------+-------+-------+-------+-------+
| 7 | > Which company conducted the  |       |       |       |       |
|   | > most recent system test?     |       |       |       |       |
+---+--------------------------------+-------+-------+-------+-------+
| 8 | > Did protection system pass   |  Y  | >  Y | >  Y |  Y  |
|   | > its most recent test?        | N     | >  N | >  N | N     |
+---+--------------------------------+-------+-------+-------+-------+
| 9 | If repaired, was the system    |  Y  |  Y  | >  Y | >  Y |
|   | tested within 6 months of the  | N     | N     | >  N | >  N |
|   | repair?                        |       |       |       |       |
+---+--------------------------------+-------+-------+-------+-------+
| 1 | Notes:                         |       |       |       |       |
| 0 |                                |       |       |       |       |
+---+--------------------------------+-------+-------+-------+-------+
| * | ***Impressed current cathodic  | *     | *     | *     | *     |
| * | protection(ICCP)***            | *Tank | *Tank | *Tank | *Tank |
| * |                                | #1**  | #2**  | #3**  | #4**  |
| B |                                |       |       |       |       |
| . |                                |       |       |       |       |
| * |                                |       |       |       |       |
| * |                                |       |       |       |       |
| * |                                |       |       |       |       |
+---+--------------------------------+-------+-------+-------+-------+
| 1 | When was the ICCP system       |       |       |       |       |
|   | installed?                     |       |       |       |       |
+---+--------------------------------+-------+-------+-------+-------+
| 2 | Does the ICCP system operate   |  Y  | >  Y | >  Y |  Y  |
|   | continuously?                  | N     | >  N | >  N | N     |
+---+--------------------------------+-------+-------+-------+-------+
| 3 | Was the rectifier inspected    | >  Y | >  Y | >  Y | >  Y |
|   | and readings recorded every 60 | >  N | >  N | >  N | >  N |
|   | days?                          | >     | >     | >     | >     |
|   |                                | >    | >    | >    | >    |
|   |                                | > NR  | > NR  | > NR  | > NR  |
|   |                                | >    | >    | >    | >    |
|   |                                | > RR  | > RR  | > RR  | > RR  |
+---+--------------------------------+-------+-------+-------+-------+
| 4 | > When was the most recent     |  Y  | >  Y | >  Y |  Y  |
|   | > system inspection?           | N     | >  N | >  N | N     |
+---+--------------------------------+-------+-------+-------+-------+
| 5 | > Do records indicate adequate |       |       |       |       |
|   | > protection?                  |       |       |       |       |
+---+--------------------------------+-------+-------+-------+-------+
| 6 | Was the ICCP system tested     | >  Y | >  Y | >  Y | >  Y |
|   | within the last 3 years?       | >  N | >  N | >  N | >  N |
|   |                                |       | >     | >     | >     |
|   |                                |  NR  | >    | >    | >    |
|   |                                |  RR  | > NR  | > NR  | > NR  |
|   |                                |       | >    | >    | >    |
|   |                                |       | > RR  | > RR  | > RR  |
+---+--------------------------------+-------+-------+-------+-------+
| 7 | > When was the most recent     |       |       |       |       |
|   | > ICCP system test?            |       |       |       |       |
+---+--------------------------------+-------+-------+-------+-------+
| 8 | > Which company conducted the  |       |       |       |       |
|   | > most recent test?            |       |       |       |       |
+---+--------------------------------+-------+-------+-------+-------+
| 9 | > Did the protection system    |  Y  | >  Y | >  Y | >  Y |
|   | > pass its most recent test?   | N     | >  N | >  N | >  N |
+---+--------------------------------+-------+-------+-------+-------+
| 1 | > If repaired, was the         |  Y  | >  Y | >  Y | >  Y |
| 0 | > protection system tested     | N     | >  N | >  N | >  N |
|   | > within 6 months of the       |       |       |       |       |
|   | > repair?                      |  Unk |       |       |       |
+---+--------------------------------+-------+-------+-------+-------+
| 1 | Notes:                         |       |       |       |       |
| 1 |                                |       |       |       |       |
+---+--------------------------------+-------+-------+-------+-------+
| * | ***Interior Liner***           | *     | *     | *     | *     |
| * |                                | *Tank | *Tank | *Tank | *Tank |
| * |                                | #1**  | #2**  | #3**  | #4**  |
| C |                                |       |       |       |       |
| . |                                |       |       |       |       |
| * |                                |       |       |       |       |
| * |                                |       |       |       |       |
| * |                                |       |       |       |       |
+---+--------------------------------+-------+-------+-------+-------+
| 1 | When was the tank lined?       |       |       |       |       |
+---+--------------------------------+-------+-------+-------+-------+
| 2 | Was the tank liner inspection  | >  Y | >  Y | >  Y | >  Y |
|   | within the last 10 years?      | >  N | >  N | >  N | >  N |
|   |                                | >     | >     | >     | >     |
|   |                                | >    | >    | >    | >    |
|   |                                | > NR  | > NR  | > NR  | > NR  |
|   |                                | >    | >    | >    | >    |
|   |                                | > RR  | > RR  | > RR  | > RR  |
+---+--------------------------------+-------+-------+-------+-------+
| 3 | > Date of the most recent      |       |       |       |       |
|   | > liner inspection?            |       |       |       |       |
+---+--------------------------------+-------+-------+-------+-------+
| 4 | > Did the tank pass its most   |  Y  | >  Y | >  Y | >  Y |
|   | > recent liner inspection?     | N     | >  N | >  N | >  N |
+---+--------------------------------+-------+-------+-------+-------+
| 5 | Notes:                         |       |       |       |       |
+---+--------------------------------+-------+-------+-------+-------+

# 

# V. Piping Cathodic Protection 

<table>
<colgroup>
<col style="width: 5%" />
<col style="width: 0%" />
<col style="width: 41%" />
<col style="width: 1%" />
<col style="width: 5%" />
<col style="width: 6%" />
<col style="width: 0%" />
<col style="width: 5%" />
<col style="width: 6%" />
<col style="width: 0%" />
<col style="width: 5%" />
<col style="width: 6%" />
<col style="width: 0%" />
<col style="width: 6%" />
<col style="width: 6%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="2"><em><strong>A.</strong></em></td>
<td colspan="2"><em><strong>Sacrificial Anodes</strong></em></td>
<td colspan="3"><strong>Tank #1</strong></td>
<td colspan="3"><strong>Tank #2</strong></td>
<td colspan="3"><strong>Tank #3</strong></td>
<td colspan="2"><strong>Tank #4</strong></td>
</tr>
<tr class="even">
<td colspan="2">1</td>
<td colspan="2">Were sacrificial anodes originally field-installed with
the piping?</td>
<td colspan="3"> Y  N</td>
<td colspan="3"> Y  N</td>
<td colspan="3"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td colspan="2">2</td>
<td colspan="2">Were supplemental anodes field-installed at a later
date?</td>
<td colspan="3"> Y  N</td>
<td colspan="3"> Y  N</td>
<td colspan="3"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td colspan="2">3</td>
<td colspan="2"><blockquote>
<p>When did the supplemental installation take place?</p>
</blockquote></td>
<td colspan="3"> Y  N</td>
<td colspan="3"> Y  N</td>
<td colspan="3"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td colspan="2">4</td>
<td colspan="2">Were the original and supplemental installation
performed by a qualified professional?</td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2">5</td>
<td colspan="2">Was the protection system tested within the last 3
years?</td>
<td colspan="3"> Y  N</td>
<td colspan="3"> Y  N</td>
<td colspan="3"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td colspan="2">6</td>
<td colspan="2"><blockquote>
<p>When was the most recent test?</p>
</blockquote></td>
<td colspan="3"> Y  N</td>
<td colspan="3"> Y  N</td>
<td colspan="3"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td colspan="2">7</td>
<td colspan="2"><blockquote>
<p>Which company conducted the most recent system test?</p>
</blockquote></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2">8</td>
<td colspan="2"><blockquote>
<p>Did the protection system pass its most recent test?</p>
</blockquote></td>
<td colspan="3"> Y  N</td>
<td colspan="3"> Y  N</td>
<td colspan="3"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td colspan="2">9</td>
<td colspan="2"><blockquote>
<p>If repaired, was the protection system tested within 6 months of the
repair?</p>
</blockquote></td>
<td colspan="3"> Y  N</td>
<td colspan="3"> Y  N</td>
<td colspan="3"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td colspan="2">10</td>
<td colspan="13">Notes</td>
</tr>
<tr class="even">
<td colspan="2"><em><strong>B.</strong></em></td>
<td colspan="2"><em><strong>Impressed current cathodic protection
(ICCP)</strong></em></td>
<td colspan="3"><strong>Tank #1</strong></td>
<td colspan="3"><strong>Tank #2</strong></td>
<td colspan="3"><strong>Tank #3</strong></td>
<td colspan="2"><strong>Tank #4</strong></td>
</tr>
<tr class="odd">
<td colspan="2">1</td>
<td colspan="2">When was the ICCP system installed?</td>
<td colspan="3"><blockquote>
<p> Y  N</p>
</blockquote></td>
<td colspan="3"> Y  N</td>
<td colspan="3"> Y  N</td>
<td colspan="2"><blockquote>
<p> Y  N</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="2">2</td>
<td colspan="2">Does the ICCP system operate continuously?</td>
<td colspan="3"><blockquote>
<p> Y  N</p>
</blockquote></td>
<td colspan="3"> Y  N</td>
<td colspan="3"> Y  N</td>
<td colspan="2"><blockquote>
<p> Y  N</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="2">3</td>
<td colspan="2">Was the rectifier inspected and readings recorded within
the last 60 days?</td>
<td colspan="3"><blockquote>
<p> Y  N</p>
</blockquote></td>
<td colspan="3"><blockquote>
<p> Y  N</p>
</blockquote></td>
<td colspan="3"><blockquote>
<p> Y  N</p>
</blockquote></td>
<td colspan="2"><blockquote>
<p> Y  N</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="2">4</td>
<td colspan="2"><blockquote>
<p>When was the most recent system inspection?</p>
</blockquote></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2">5</td>
<td colspan="2"><blockquote>
<p>Do records indicate adequate protection?</p>
</blockquote></td>
<td colspan="3"><blockquote>
<p> Y  N</p>
</blockquote></td>
<td colspan="3"><blockquote>
<p> Y  N</p>
</blockquote></td>
<td colspan="3"><blockquote>
<p> Y  N</p>
</blockquote></td>
<td colspan="2"><blockquote>
<p> Y  N</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="2">6</td>
<td colspan="2">Was the ICCP system tested within the last 3 years?</td>
<td colspan="3"><blockquote>
<p> Y  N</p>
</blockquote></td>
<td colspan="3"><blockquote>
<p> Y  N</p>
</blockquote></td>
<td colspan="3"><blockquote>
<p> Y  N</p>
</blockquote></td>
<td colspan="2"><blockquote>
<p> Y  N</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="2">7</td>
<td colspan="2"><blockquote>
<p>When was the most recent ICCP system test??</p>
</blockquote></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2">8</td>
<td colspan="2"><blockquote>
<p>Which company conducted the most recent test?</p>
</blockquote></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2">9</td>
<td colspan="2"><blockquote>
<p>Did the system pass its most recent test?</p>
</blockquote></td>
<td colspan="3"><blockquote>
<p> Y  N</p>
</blockquote></td>
<td colspan="3"><blockquote>
<p> Y  N</p>
</blockquote></td>
<td colspan="3"><blockquote>
<p> Y  N</p>
</blockquote></td>
<td colspan="2"><blockquote>
<p> Y  N</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="2">10</td>
<td colspan="2"><blockquote>
<p>If repaired, was the protection system tested within 6 months of the
repair?</p>
</blockquote></td>
<td colspan="3"><blockquote>
<p> Y  N</p>
</blockquote></td>
<td colspan="3"><blockquote>
<p> Y  N</p>
</blockquote></td>
<td colspan="3"><blockquote>
<p> Y  N</p>
</blockquote></td>
<td colspan="2"><blockquote>
<p> Y  N</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="2">11</td>
<td colspan="13">Notes:</td>
</tr>
<tr class="even">
<td><em><strong>C.</strong></em></td>
<td colspan="2"><em><strong>Ancillary Equipment Corrosion
Protection</strong></em></td>
<td colspan="3"><strong>Tank #1</strong></td>
<td colspan="3"><strong>Tank #2</strong></td>
<td colspan="3"><strong>Tank #3</strong></td>
<td colspan="3"><strong>Tank #4</strong></td>
</tr>
<tr class="odd">
<td>1</td>
<td colspan="2">What other equipment is in contact with soils? [Check
all that apply.]</td>
<td colspan="2"><p> FC</p>
<p> SJ</p>
<p> PH</p></td>
<td><p> VR</p>
<ul>
<li><p>O</p></li>
<li><p>Unk</p></li>
</ul></td>
<td colspan="2"><p> FC</p>
<p> SJ</p>
<p> PH</p></td>
<td><p> VR</p>
<ul>
<li><p>O</p></li>
<li><p>Unk</p></li>
</ul></td>
<td colspan="2"><p> FC</p>
<p> SJ</p>
<p> PH</p></td>
<td><p> VR</p>
<ul>
<li><p>O</p></li>
<li><p>Unk</p></li>
</ul></td>
<td colspan="2"><p> FC</p>
<p> SJ</p>
<p> PH</p></td>
<td><p> VR</p>
<ul>
<li><p>O</p></li>
<li><p>Unk</p></li>
</ul></td>
</tr>
<tr class="even">
<td>2</td>
<td colspan="2">If other, please specify:</td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td>3</td>
<td colspan="2">Is any of the additional equipment metallic?</td>
<td colspan="3"> Y  N</td>
<td colspan="3"> Y  N</td>
<td colspan="3"> Y  N</td>
<td colspan="3"> Y  N</td>
</tr>
<tr class="even">
<td>4</td>
<td colspan="2">Is all metal equipment protected from corrosion or
isolated from contacting the earth?</td>
<td colspan="3"><p> Y  N</p>
<p> Unk</p></td>
<td colspan="3"><p> Y  N</p>
<p> Unk</p></td>
<td colspan="3"><p> Y  N</p>
<p> Unk</p></td>
<td colspan="3"><p> Y  N</p>
<p> Unk</p></td>
</tr>
<tr class="odd">
<td>5</td>
<td colspan="2">Please note all methods of complying with corrosion
protection standards for ancillary equipment [Check all that
apply.]</td>
<td colspan="2"><p> ISO</p>
<p> ICCP</p></td>
<td><p> SACP</p>
<p> O</p>
<p> Unk</p></td>
<td colspan="2"><p> ISO</p>
<p> ICCP</p></td>
<td><p> SACP</p>
<p> O</p>
<p> Unk</p></td>
<td colspan="2"><p> ISO</p>
<p> ICCP</p></td>
<td><p> SACP</p>
<p> O</p>
<p> Unk</p></td>
<td colspan="2"><p> ISO</p>
<p> ICCP</p></td>
<td><p> SACP</p>
<p> O</p>
<p> Unk</p></td>
</tr>
<tr class="even">
<td>6</td>
<td colspan="2"><blockquote>
<p>If Other, please specify:</p>
</blockquote></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td>7</td>
<td colspan="14">Notes:</td>
</tr>
</tbody>
</table>

# VI. Tank Leak Detection

<table>
<colgroup>
<col style="width: 4%" />
<col style="width: 42%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
</colgroup>
<tbody>
<tr class="odd">
<td><em><strong>A.</strong></em></td>
<td><em><strong>Leak Detection System Status</strong></em></td>
<td colspan="2"><strong>Tank #1</strong></td>
<td colspan="2"><strong>Tank #2</strong></td>
<td colspan="2"><strong>Tank #3</strong></td>
<td colspan="2"><strong>Tank #4</strong></td>
</tr>
<tr class="even">
<td>1</td>
<td><p>What kind of leak detection does the tank have?</p>
<p>[Check all that apply]</p></td>
<td><blockquote>
<p> ALT</p>
<p> Ie</p>
<p> Im</p>
<p> ATG</p>
</blockquote></td>
<td><p> MTG</p>
<p> VAP</p>
<p> GWM</p>
<p> O</p>
<p><em>(specify)</em></p></td>
<td><blockquote>
<p> ALT</p>
<p> Ie</p>
<p> Im</p>
<p> ATG</p>
</blockquote></td>
<td><p> MTG</p>
<p> VAP</p>
<p> GWM</p>
<p> O</p>
<p><em>(specify)</em></p></td>
<td><blockquote>
<p> ALT</p>
<p> Ie</p>
<p> Im</p>
<p> ATG</p>
</blockquote></td>
<td><p> MTG</p>
<p> VAP</p>
<p> GWM</p>
<p> O</p>
<p><em>(specify)</em></p></td>
<td><blockquote>
<p> ALT</p>
<p> Ie</p>
<p> Im</p>
<p> ATG</p>
</blockquote></td>
<td><p> MTG</p>
<p> VAP</p>
<p> GWM</p>
<p> O</p>
<p><em>(specify)</em></p></td>
</tr>
<tr class="odd">
<td>2</td>
<td><blockquote>
<p>If other, please specify:</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>3</td>
<td colspan="9">Notes:</td>
</tr>
<tr class="odd">
<td><em><strong>B.</strong></em></td>
<td><em><strong>Electronic Interstitial
Monitoring(Ie)</strong></em></td>
<td colspan="2"><strong>Tank #1</strong></td>
<td colspan="2"><strong>Tank #2</strong></td>
<td colspan="2"><strong>Tank #3</strong></td>
<td colspan="2"><strong>Tank #4</strong></td>
</tr>
<tr class="even">
<td>1</td>
<td>Provide make of system</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>2</td>
<td>Provide model type/number of system</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>3</td>
<td>When was the system installed?</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>4</td>
<td>Do records indicate that the system has been monitored weekly over
the past year?</td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
</tr>
<tr class="even">
<td>5</td>
<td>Do records indicate that the monitoring system been inspected in the
past year?</td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
</tr>
<tr class="odd">
<td>6</td>
<td><blockquote>
<p>What was the date of the inspection?</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>7</td>
<td><blockquote>
<p>Which company conducted the inspection?</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>8</td>
<td>Is the monitoring system currently operating?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td>9</td>
<td>Was sensor operation and installation verified during the
inspection?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td>10</td>
<td><blockquote>
<p>Was the sensor installed at the lowest portion of the secondary
containment sump?</p>
</blockquote></td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td>11</td>
<td><blockquote>
<p>If the sensor operation was verified, did the monitoring console
express an alarm condition?</p>
</blockquote></td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td>12</td>
<td>Does the self-test button indicate that the monitor is working
correctly?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td>13</td>
<td>Does the system status indicate any problems?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td>14</td>
<td>Is system in alarm mode?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td>15</td>
<td>If yes, what was the Problem / Alarm?</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>16</td>
<td colspan="9">Notes:</td>
</tr>
<tr class="even">
<td><em><strong>C.</strong></em></td>
<td><em><strong>Manual Interstitial Monitoring (Im)</strong></em></td>
<td colspan="2"><strong>Tank #1</strong></td>
<td colspan="2"><strong>Tank #2</strong></td>
<td colspan="2"><strong>Tank #3</strong></td>
<td colspan="2"><strong>Tank #4</strong></td>
</tr>
<tr class="odd">
<td>1</td>
<td>Do records indicate that the system has been monitored weekly over
the past year?</td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
</tr>
<tr class="even">
<td>2</td>
<td>Was the interstice monitoring port readily accessible?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td>3</td>
<td>Was monitoring equipment available at the facility?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td>4</td>
<td>Results of monitoring during inspection:</td>
<td colspan="2"><p> Prod</p>
<p> H<sub>2</sub>O</p></td>
<td colspan="2"> Dry</td>
<td colspan="2"><p> Prod</p>
<p> H<sub>2</sub>O</p></td>
<td colspan="2"> Dry</td>
</tr>
<tr class="odd">
<td>5</td>
<td colspan="9">Notes:</td>
</tr>
<tr class="even">
<td><em><strong>D.</strong></em></td>
<td><em><strong>Automatic Tank Gauge (ATG)</strong></em></td>
<td colspan="2"><strong>Tank #1</strong></td>
<td colspan="2"><strong>Tank #2</strong></td>
<td colspan="2"><strong>Tank #3</strong></td>
<td colspan="2"><strong>Tank #4</strong></td>
</tr>
<tr class="odd">
<td>1</td>
<td>Provide make of system?</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>2</td>
<td>Provide model type/number of system?</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>3</td>
<td>When was the ATG installed?</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>4</td>
<td>Do records indicate the ATG system was inspected in the past
year?</td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
</tr>
<tr class="odd">
<td>5</td>
<td><blockquote>
<p>When was the inspection performed?</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>6</td>
<td><blockquote>
<p>Which company conducted the inspection?</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>7</td>
<td>Is the equipment capable of at least 0.2 GPH accuracy?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td>8</td>
<td>Do records indicate that the ATG has been used to conduct at least
one 0.2 gallon/hour leak rate test weekly? [If yes, see items
below.]</td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
</tr>
<tr class="odd">
<td>9</td>
<td><blockquote>
<p>When was the most recent test?</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>10</td>
<td><blockquote>
<p>Did the tank pass the most recent 0.2 GPH test?</p>
</blockquote></td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td>11</td>
<td><blockquote>
<p>Do records indicate that weekly 0.2 GPH tests have been conducted
over last year?</p>
</blockquote></td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td>12</td>
<td colspan="9">Notes:</td>
</tr>
<tr class="odd">
<td><em><strong>E.</strong></em></td>
<td><em><strong>Inventory Control</strong></em></td>
<td colspan="2"><strong>Tank #1</strong></td>
<td colspan="2"><strong>Tank #2</strong></td>
<td colspan="2"><strong>Tank #3</strong></td>
<td colspan="2"><strong>Tank #4</strong></td>
</tr>
<tr class="even">
<td>1</td>
<td>Is the measuring equipment used capable of measuring to the nearest
1/8" over the entire height of the tank?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td>2</td>
<td>Do records indicate that all data are reconciled at least once every
30 days?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td>3</td>
<td>Do records indicate that inventory and dispenser readings are taken
every day that product is added or removed from the tank?</td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
</tr>
<tr class="odd">
<td>4</td>
<td>Do records indicate that inventory and dispenser readings are
reconciled at least once on each day that fuel is added to or removed
from the tank?</td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
</tr>
<tr class="even">
<td>5</td>
<td>Do records indicate that inventory readings are taken before and
after each fuel delivery?</td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
</tr>
<tr class="odd">
<td>6</td>
<td>Do records indicate that fuel deliveries are reconciled with
delivery receipts by taking inventory readings before and after each
delivery?</td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
</tr>
<tr class="even">
<td>7</td>
<td>Are records available for the last 12 months of inventory
control?</td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
</tr>
<tr class="odd">
<td>8</td>
<td>Do records indicate that 1% flow-through plus 130 gallons variance
is calculated?</td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<ul>
<li><p> NR  RR</p></li>
</ul></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
</tr>
<tr class="even">
<td>9</td>
<td><blockquote>
<p>If so, has the variance exceeded two consecutive months over the last
12 months?</p>
</blockquote></td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td>10</td>
<td><blockquote>
<p>If yes, has DEC been notified?</p>
</blockquote></td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td>11</td>
<td>Do records indicate that water in the tank is measured at least once
every 30 days?</td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
</tr>
<tr class="odd">
<td>12</td>
<td colspan="9">Notes:</td>
</tr>
<tr class="even">
<td><em><strong>F.</strong></em></td>
<td><em><strong>Manual Tank Gauge</strong></em></td>
<td colspan="2"><strong>Tank #1</strong></td>
<td colspan="2"><strong>Tank #2</strong></td>
<td colspan="2"><strong>Tank #3</strong></td>
<td colspan="2"><strong>Tank #4</strong></td>
</tr>
<tr class="odd">
<td>1</td>
<td>Is the gauge stick accurate to 1/8"?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td>2</td>
<td>Do records indicate that measurement is taken to 1/8" accuracy?</td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
</tr>
<tr class="odd">
<td>3</td>
<td>Do records indicate that measurements are taken before and after the
required idle period?</td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
</tr>
<tr class="even">
<td>4</td>
<td>Is the tank idle for at least 36 hours once a week for liquid level
measurements?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td>5</td>
<td><blockquote>
<p>Does the most recent gauging event indicate a suspected release?</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>6</td>
<td>Is the average of four weekly gauging events reconciled once a
month?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td>7</td>
<td>Notes:</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td><em><strong>G.</strong></em></td>
<td><em><strong>Alternate Methods</strong></em></td>
<td colspan="2"><strong>Tank #1</strong></td>
<td colspan="2"><strong>Tank #2</strong></td>
<td colspan="2"><strong>Tank #3</strong></td>
<td colspan="2"><strong>Tank #4</strong></td>
</tr>
<tr class="odd">
<td>1</td>
<td>Is the alternate method approved by DEC?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td>2</td>
<td>Is the alternate method capable of detecting leaks?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td>3</td>
<td>Are there sufficient records to indicate consistent leak
detection?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td>4</td>
<td colspan="9">Notes:</td>
</tr>
</tbody>
</table>

# VII. Piping Leak Detection

<table style="width:100%;">
<colgroup>
<col style="width: 3%" />
<col style="width: 43%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
</colgroup>
<tbody>
<tr class="odd">
<td><strong>A.</strong></td>
<td><em><strong>Leak Detection System Status</strong></em></td>
<td colspan="2"><strong>Tank #1</strong></td>
<td colspan="2"><strong>Tank #2</strong></td>
<td colspan="2"><strong>Tank #3</strong></td>
<td colspan="2"><strong>Tank #4</strong></td>
</tr>
<tr class="even">
<td>1</td>
<td>What kind of leak detection does the piping have?.</td>
<td><blockquote>
<p> 3LT</p>
<p> ALT</p>
<p> Ie</p>
<p> Im</p>
<p> LLD</p>
</blockquote></td>
<td><p> V</p>
<p> VAP</p>
<p> GWM</p>
<p> O</p></td>
<td><blockquote>
<p> 3LT</p>
<p> ALT</p>
<p> Ie</p>
<p> Im</p>
<p> LLD</p>
</blockquote></td>
<td><p> V</p>
<p> VAP</p>
<p> GWM</p>
<p> O</p></td>
<td><blockquote>
<p> 3LT</p>
<p> ALT</p>
<p> Ie</p>
<p> Im</p>
<p> LLD</p>
</blockquote></td>
<td><p> V</p>
<p> VAP</p>
<p> GWM</p>
<p> O</p></td>
<td><blockquote>
<p> 3LT</p>
<p> ALT</p>
<p> Ie</p>
<p> Im</p>
<p> LLD</p>
</blockquote></td>
<td><p> V</p>
<p> VAP</p>
<p> GWM</p>
<p> O</p></td>
</tr>
<tr class="odd">
<td>2</td>
<td colspan="9">Notes:</td>
</tr>
<tr class="even">
<td><em><strong>B.</strong></em></td>
<td><em><strong>Pressurized Piping (Double-Walled)</strong></em></td>
<td colspan="2"><strong>Tank #1</strong></td>
<td colspan="2"><strong>Tank #2</strong></td>
<td colspan="2"><strong>Tank #3</strong></td>
<td colspan="2"><strong>Tank #4</strong></td>
</tr>
<tr class="odd">
<td>1</td>
<td>Is interstitial monitoring used to check for leaks?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td>2</td>
<td>Is monitoring conducted <u>cont</u>inuously or <u>week</u>ly</td>
<td colspan="2"> Cont  Week</td>
<td colspan="2"> Cont  Week</td>
<td colspan="2"> Cont  Week</td>
<td colspan="2"> Cont  Week</td>
</tr>
<tr class="odd">
<td>3</td>
<td>Is monitoring conducted <u>elec</u>tronically or
<u>man</u>ually?</td>
<td colspan="2"> Elec  Man</td>
<td colspan="2"> Elec  Man</td>
<td colspan="2"> Elec  Man</td>
<td colspan="2"> Elec  Man</td>
</tr>
<tr class="even">
<td>4</td>
<td>If electronic, provide make of monitoring system.</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>5</td>
<td><blockquote>
<p>Provide model of monitoring system.</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>6</td>
<td>Are the secondary containment sumps (sumps) free of water, debris,
and product?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td>7</td>
<td><blockquote>
<p>If no, describe:</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>8</td>
<td>Do the sumps appear to have integrity?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td>9</td>
<td><blockquote>
<p>If no, describe</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>10</td>
<td>If manual monitoring in conducted, has a monitoring log been used to
record monitoring events?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td>11</td>
<td><blockquote>
<p>Does monitoring log accurately reflect the conditions observed during
inspection?</p>
</blockquote></td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td>12</td>
<td>If electronic, are the sumps equipped with sensors for continuous
monitoring?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td>13</td>
<td><blockquote>
<p>Are the sensors upright and set at correct height?</p>
</blockquote></td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td>14</td>
<td><blockquote>
<p>Are the sensors functioning properly?</p>
</blockquote></td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td>15</td>
<td>Are all entries (boots) sealed to prevent infiltration of water or
release of product?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td>16</td>
<td>Is the secondary piping test boost disconnected?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td>17</td>
<td>If electronic, has the monitoring system been inspected or repaired
within the past 12 months?</td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
</tr>
<tr class="even">
<td>18</td>
<td><blockquote>
<p>Are records available of system inspections or repairs?</p>
</blockquote></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
</tr>
<tr class="odd">
<td>19</td>
<td><blockquote>
<p>When was the last inspection performed?</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>20</td>
<td><blockquote>
<p>Which company performed the work?</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>21</td>
<td>Is the submersible turbine pump (STP) equipped with a automatic line
leak detector (LLD)?</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>22</td>
<td>Was a LLD test conducted within the last year?</td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
</tr>
<tr class="odd">
<td>23</td>
<td><blockquote>
<p>When was the most recent LLD test conducted?</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>24</td>
<td><blockquote>
<p>Are records available for that LLD test?</p>
</blockquote></td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td>25</td>
<td><blockquote>
<p>Do records indicate a passing test result?</p>
</blockquote></td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td>26</td>
<td><blockquote>
<p>If no, was the LLD replaced?</p>
</blockquote></td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td>27</td>
<td><blockquote>
<p>If yes, was the replacement LLD tested?</p>
</blockquote></td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td>28</td>
<td><blockquote>
<p>Which company conducted the test?</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>29</td>
<td colspan="9">Notes:</td>
</tr>
<tr class="even">
<td><em><strong>C.</strong></em></td>
<td><em><strong>Containment Sumps (intermediary or
dispenser)</strong></em></td>
<td colspan="2"><strong>Tank #1</strong></td>
<td colspan="2"><strong>Tank #2</strong></td>
<td colspan="2"><strong>Tank #3</strong></td>
<td colspan="2"><strong>Tank #4</strong></td>
</tr>
<tr class="odd">
<td>1</td>
<td>How many additional containment sumps does the system have?
<em>(note if dispenser sumps).</em></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>2</td>
<td>Are the sumps required to be monitored?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td>3</td>
<td>Is monitoring conducted <u>cont</u>inuously or <u>week</u>ly</td>
<td colspan="2"> Cont  Week</td>
<td colspan="2"> Cont  Week</td>
<td colspan="2"> Cont  Week</td>
<td colspan="2"> Cont  Week</td>
</tr>
<tr class="even">
<td>4</td>
<td>Is monitoring conducted <u>elec</u>tronically or
<u>man</u>ually?</td>
<td colspan="2"> Elec  Man</td>
<td colspan="2"> Elec  Man</td>
<td colspan="2"> Elec  Man</td>
<td colspan="2"> Elec  Man</td>
</tr>
<tr class="odd">
<td>5</td>
<td>If electronic, provide make of monitoring system.</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>6</td>
<td><blockquote>
<p>Provide model of monitoring system.</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>7</td>
<td>Are the secondary containment sumps (sumps) free of water, debris,
and product?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td>8</td>
<td><blockquote>
<p>If no, describe:</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>9</td>
<td>Do the sumps appear to have integrity?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td>10</td>
<td><blockquote>
<p>If no, describe</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>11</td>
<td>If manual monitoring in conducted, has a monitoring log been used to
record monitoring events?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td>12</td>
<td><blockquote>
<p>Does monitoring log accurately reflect the conditions observed during
inspection?</p>
</blockquote></td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td>13</td>
<td>If electronic, are the sumps equipped with sensors for continuous
monitoring?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td>14</td>
<td><blockquote>
<p>Are the sensors upright and set at correct height?</p>
</blockquote></td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td>15</td>
<td><blockquote>
<p>Are the sensors functioning properly?</p>
</blockquote></td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td>16</td>
<td>Are all entries (boots) sealed to prevent infiltration of water or
release of product?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td>17</td>
<td>Is the secondary piping test boost disconnected?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td>18</td>
<td>Notes:</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td><em><strong>D.</strong></em></td>
<td><em><strong>Pressurized Piping (Single-Walled)</strong></em></td>
<td colspan="2"><strong>Tank #1</strong></td>
<td colspan="2"><strong>Tank #2</strong></td>
<td colspan="2"><strong>Tank #3</strong></td>
<td colspan="2"><strong>Tank #4</strong></td>
</tr>
<tr class="even">
<td>1</td>
<td>Has an annual tightness test been conducted for this piping
run?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td>2</td>
<td><blockquote>
<p>When was the most recent tightness test conducted?</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>3</td>
<td><blockquote>
<p>Are records available for that tightness test?</p>
</blockquote></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
</tr>
<tr class="odd">
<td>4</td>
<td><blockquote>
<p>Do records indicate a passing test result?</p>
</blockquote></td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td>5</td>
<td><blockquote>
<p>Which company conducted the most recent tightness test?</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>6</td>
<td>Is the submersible turbine pump (STP) equipped with a automatic line
leak detector (LLD)?</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>7</td>
<td>Was a LLD test conducted within the last year?</td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
</tr>
<tr class="odd">
<td>8</td>
<td><blockquote>
<p>When was the most recent LLD test conducted?</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>9</td>
<td><blockquote>
<p>Are records available for that LLD test?</p>
</blockquote></td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td>10</td>
<td><blockquote>
<p>Do records indicate a passing test result?</p>
</blockquote></td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td>11</td>
<td><blockquote>
<p>If no, was the LLD replaced?</p>
</blockquote></td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td>12</td>
<td><blockquote>
<p>If yes, was the replacement LLD tested?</p>
</blockquote></td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td>13</td>
<td><blockquote>
<p>Which company conducted the LLD test?</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>14</td>
<td>Notes:</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td><em><strong>E.</strong></em></td>
<td><em><strong>Exempt Suction Piping</strong></em></td>
<td colspan="2"><strong>Tank #1</strong></td>
<td colspan="2"><strong>Tank #2</strong></td>
<td colspan="2"><strong>Tank #3</strong></td>
<td colspan="2"><strong>Tank #4</strong></td>
</tr>
<tr class="odd">
<td>1</td>
<td>Are vertical check valves installed only at the dispenser end of
each piping run?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td>2</td>
<td>Does each piping run slope 1/8" per 1.0' from the dispenser to the
tank?</td>
<td colspan="2"><p> Y  N</p>
<p> Unk</p></td>
<td colspan="2"><p> Y  N</p>
<p> Unk</p></td>
<td colspan="2"><p> Y  N</p>
<p> Unk</p></td>
<td colspan="2"><p> Y  N</p>
<p> Unk</p></td>
</tr>
<tr class="odd">
<td>3</td>
<td>Notes:</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td><em><strong>F.</strong></em></td>
<td><em><strong>Non-Exempt Suction Piping</strong></em></td>
<td colspan="2"><strong>Tank #1</strong></td>
<td colspan="2"><strong>Tank #2</strong></td>
<td colspan="2"><strong>Tank #3</strong></td>
<td colspan="2"><strong>Tank #4</strong></td>
</tr>
<tr class="odd">
<td>1</td>
<td>Do records indicate that at least one tightness test has been
conducted?</td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
</tr>
<tr class="even">
<td>2</td>
<td><blockquote>
<p>When was the most recent tightness test?</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>3</td>
<td><blockquote>
<p>Which company conducted the most recent tightness test?</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>4</td>
<td><blockquote>
<p>Did the piping run pass the test?</p>
</blockquote></td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td>5</td>
<td><blockquote>
<p>Do records indicate a tightness test was performed in the last 3
years?</p>
</blockquote></td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td>6</td>
<td><blockquote>
<p>Are passing results available for the most recent test?</p>
</blockquote></td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td>7</td>
<td>Is interstitial monitoring used continuously to check for
leaks?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td>8</td>
<td><blockquote>
<p>Are records available of system checks within the past 12 months?</p>
</blockquote></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
</tr>
<tr class="odd">
<td>9</td>
<td><blockquote>
<p>Are records available of system repairs within the past 12
months?</p>
</blockquote></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
</tr>
<tr class="even">
<td>10</td>
<td><blockquote>
<p>Has the continuous monitoring system been inspected in the past
year?</p>
</blockquote></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
</tr>
<tr class="odd">
<td>11</td>
<td><blockquote>
<p>When was the most recent calibration inspection?</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>12</td>
<td>Which company conducted the most recent calibration inspection?</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>13</td>
<td colspan="9">Notes:</td>
</tr>
<tr class="even">
<td><em><strong>G.</strong></em></td>
<td><em><strong>Alternate Methods</strong></em></td>
<td colspan="2"><strong>Tank #1</strong></td>
<td colspan="2"><strong>Tank #2</strong></td>
<td colspan="2"><strong>Tank #3</strong></td>
<td colspan="2"><strong>Tank #4</strong></td>
</tr>
<tr class="odd">
<td>1</td>
<td>Is the alternate method capable of detecting leaks?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td>2</td>
<td>Are sufficient records kept to indicate consistent leak
detection?</td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
<td colspan="2"><p> Y  N</p>
<p> NR  RR</p></td>
</tr>
<tr class="odd">
<td>3</td>
<td>Is alternate method approved by DEC?</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
</tbody>
</table>

# VIII. Spill and Overfill Prevention

+---+---+------------------------------+--------+--------+--------+--------+
| * |   | ***Spill Containment***      | **Tank | **Tank | **Tank | **Tank |
| * |   |                              | #1**   | #2**   | #3**   | #4**   |
| * |   |                              |        |        |        |        |
| A |   |                              |        |        |        |        |
| . |   |                              |        |        |        |        |
| * |   |                              |        |        |        |        |
| * |   |                              |        |        |        |        |
| * |   |                              |        |        |        |        |
+---+---+------------------------------+--------+--------+--------+--------+
| 1 |   | Is the tank equipped with a  |  Y   |  Y   |  Y   |  Y   |
|   |   | spill containment manhole    | N      | N      | N      | N      |
|   |   | (i.e., a spill bucket)?      |        |        |        |        |
+---+---+------------------------------+--------+--------+--------+--------+
| 2 |   | > If yes, what is the size   |        |        |        |        |
|   |   | > of the spill bucket (in    |        |        |        |        |
|   |   | >                            |        |        |        |        |
|   |   | > gallons)?                  |        |        |        |        |
+---+---+------------------------------+--------+--------+--------+--------+
| 1 |   | Is the device currently      |  Y   |  Y   |  Y   |  Y   |
|   |   | operational (i.e., free of   | N      | N      | N      | N      |
|   |   | cracks, holes, water,        |        |        |        |        |
|   |   | debris, and product)?        |        |        |        |        |
+---+---+------------------------------+--------+--------+--------+--------+
| 2 |   | Is each spill bucket         |  Y   |  Y   |  Y   |  Y   |
|   |   | surrounded by impervious     | N      | N      | N      | N      |
|   |   | surface?                     |        |        |        |        |
+---+---+------------------------------+--------+--------+--------+--------+
| 4 |   | Do records show that spill   |  Y   |  Y   |  Y   |  Y   |
|   |   | buckets are inspected for    | N      | N      | N      | N      |
|   |   | wear, cracks, holes, water,  |        |        |        |        |
|   |   | debris, and product at every |        |        |        |        |
|   |   | delivery?                    |        |        |        |        |
+---+---+------------------------------+--------+--------+--------+--------+
| 5 |   | Is waste from spill buckets  |  Y   |  Y   |  Y   |  Y   |
|   |   | handled properly?            | N      | N      | N      | N      |
+---+---+------------------------------+--------+--------+--------+--------+
| 6 |   | Are all fill pipes           |  Y   |  Y   |  Y   |  Y   |
|   |   | permanently labeled to       | N      | N      | N      | N      |
|   |   | identify the substance       |        |        |        |        |
|   |   | stored?                      |        |        |        |        |
+---+---+------------------------------+--------+--------+--------+--------+
| 7 |   | Are all fill box covers      |  Y   |  Y   |  Y   |  Y   |
|   |   | permanently labeled to       | N      | N      | N      | N      |
|   |   | identify the substance       |        |        |        |        |
|   |   | stored?                      |        |        |        |        |
+---+---+------------------------------+--------+--------+--------+--------+
| 8 |   | Is the tank equipped with a  |  Y   |  Y   |  Y   |  Y   |
|   |   | submerged fill drop tube?    | N      | N      | N      | N      |
+---+---+------------------------------+--------+--------+--------+--------+
| 9 |   | > Are drop tubes intact      |  Y   |  Y   |  Y   |  Y   |
|   |   | > (coaxial only)?            | N      | N      | N      | N      |
|   |   |                              |        |        |        |        |
|   |   |                              |  Unk  |  Unk  |  Unk  |  Unk  |
+---+---+------------------------------+--------+--------+--------+--------+
| 1 |   | > Does the drop tube end     |  Y   |  Y   |  Y   |  Y   |
| 0 |   | > within 6" of tank bottom?  | N      | N      | N      | N      |
|   |   |                              |        |        |        |        |
|   |   |                              |  Unk  |  Unk  |  Unk  |  Unk  |
+---+---+------------------------------+--------+--------+--------+--------+
| 1 |   | Notes:                       |        |        |        |        |
| 1 |   |                              |        |        |        |        |
|   |   | []{.mark}                    |        |        |        |        |
+---+---+------------------------------+--------+--------+--------+--------+
| * | * |                              | **Tank | **Tank | **Tank | **Tank |
| * | * |                              | #1**   | #2**   | #3**   | #4**   |
| * | * |                              |        |        |        |        |
| B | O |                              |        |        |        |        |
| . | v |                              |        |        |        |        |
| * | e |                              |        |        |        |        |
| * | r |                              |        |        |        |        |
| * | f |                              |        |        |        |        |
|   | i |                              |        |        |        |        |
|   | l |                              |        |        |        |        |
|   | l |                              |        |        |        |        |
|   | P |                              |        |        |        |        |
|   | r |                              |        |        |        |        |
|   | o |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | c |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | i |                              |        |        |        |        |
|   | o |                              |        |        |        |        |
|   | n |                              |        |        |        |        |
|   | * |                              |        |        |        |        |
|   | * |                              |        |        |        |        |
|   | * |                              |        |        |        |        |
+---+---+------------------------------+--------+--------+--------+--------+
| 1 | D |                              |  Y   |  Y   |  Y   |  Y   |
|   | o |                              | N      | N      | N      | N      |
|   | t |                              |        |        |        |        |
|   | a |                              |        |        |        |        |
|   | n |                              |        |        |        |        |
|   | k |                              |        |        |        |        |
|   | s |                              |        |        |        |        |
|   | h |                              |        |        |        |        |
|   | a |                              |        |        |        |        |
|   | v |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | a |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | l |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | a |                              |        |        |        |        |
|   | s |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | o |                              |        |        |        |        |
|   | n |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | m |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | h |                              |        |        |        |        |
|   | o |                              |        |        |        |        |
|   | d |                              |        |        |        |        |
|   | o |                              |        |        |        |        |
|   | f |                              |        |        |        |        |
|   | o |                              |        |        |        |        |
|   | v |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | r |                              |        |        |        |        |
|   | f |                              |        |        |        |        |
|   | i |                              |        |        |        |        |
|   | l |                              |        |        |        |        |
|   | l |                              |        |        |        |        |
|   | p |                              |        |        |        |        |
|   | r |                              |        |        |        |        |
|   | o |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | c |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | i |                              |        |        |        |        |
|   | o |                              |        |        |        |        |
|   | n |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | h |                              |        |        |        |        |
|   | a |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | i |                              |        |        |        |        |
|   | s |                              |        |        |        |        |
|   | o |                              |        |        |        |        |
|   | p |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | r |                              |        |        |        |        |
|   | a |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | i |                              |        |        |        |        |
|   | n |                              |        |        |        |        |
|   | g |                              |        |        |        |        |
|   | p |                              |        |        |        |        |
|   | r |                              |        |        |        |        |
|   | o |                              |        |        |        |        |
|   | p |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | r |                              |        |        |        |        |
|   | l |                              |        |        |        |        |
|   | y |                              |        |        |        |        |
|   | ? |                              |        |        |        |        |
+---+---+------------------------------+--------+--------+--------+--------+
| 2 | W |                              | -   Ov | -   Ov | -   Ov | -   Ov |
|   | h |                              | erfill | erfill | erfill | erfill |
|   | a |                              |        |        |        |        |
|   | t |                              |  alarm |  alarm |  alarm |  alarm |
|   | o |                              |        |        |        |        |
|   | v |                              | -      | -      | -      | -      |
|   | e |                              |    Aut |    Aut |    Aut |    Aut |
|   | r |                              | omatic | omatic | omatic | omatic |
|   | f |                              |     s  |     s  |     s  |     s  |
|   | i |                              | hutoff | hutoff | hutoff | hutoff |
|   | l |                              |        |        |        |        |
|   | l |                              | device | device | device | device |
|   | d |                              |        |        |        |        |
|   | e |                              | -      | -      | -      | -      |
|   | v |                              |   Ball |   Ball |   Ball |   Ball |
|   | i |                              |        |        |        |        |
|   | c |                              |  float |  float |  float |  float |
|   | e |                              |        |        |        |        |
|   | o |                              |  valve |  valve |  valve |  valve |
|   | r |                              |        |        |        |        |
|   | m |                              | -      | -      | -      | -      |
|   | e |                              |   Vent |   Vent |   Vent |   Vent |
|   | t |                              |     w  |     w  |     w  |     w  |
|   | h |                              | histle | histle | histle | histle |
|   | o |                              |        |        |        |        |
|   | d |                              | -      | -      | -      | -      |
|   | d |                              |  Measu |  Measu |  Measu |  Measu |
|   | o |                              | rement | rement | rement | rement |
|   | e |                              |        |        |        |        |
|   | s |                              | -      | -      | -      | -      |
|   | e |                              |  Other |  Other |  Other |  Other |
|   | a |                              |        |        |        |        |
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|   | ? |                              |        |        |        |        |
|   | \ |                              |        |        |        |        |
|   | [ |                              |        |        |        |        |
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|   | y |                              |        |        |        |        |
|   | \ |                              |        |        |        |        |
|   | ] |                              |        |        |        |        |
+---+---+------------------------------+--------+--------+--------+--------+
| 3 | > |                              |        |        |        |        |
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+---+---+------------------------------+--------+--------+--------+--------+
| 4 | D |                              |  Y   |  Y   |  Y   |  Y   |
|   | i |                              | N      | N      | N      | N      |
|   | d |                              |        |        |        |        |
|   | a |                              |  NR  |  NR  |  NR  |  NR  |
|   | q |                              | RR     | RR     | RR     | RR     |
|   | u |                              |        |        |        |        |
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|   | m |                              |        |        |        |        |
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+---+---+------------------------------+--------+--------+--------+--------+
| 5 | N |                              |        |        |        |        |
|   | o |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | s |                              |        |        |        |        |
|   | : |                              |        |        |        |        |
+---+---+------------------------------+--------+--------+--------+--------+
| * | * |                              | **Tank | **Tank | **Tank | **Tank |
| * | * |                              | #1**   | #2**   | #3**   | #4**   |
| * | * |                              |        |        |        |        |
| C | O |                              |        |        |        |        |
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|   | * |                              |        |        |        |        |
|   | * |                              |        |        |        |        |
|   | * |                              |        |        |        |        |
+---+---+------------------------------+--------+--------+--------+--------+
| 1 | I |                              |  Y   |  Y   |  Y   |  Y   |
|   | s |                              | N      | N      | N      | N      |
|   | t |                              |        |        |        |        |
|   | h |                              |  Unk  |  Unk  |  Unk  |  Unk  |
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|   | 0 |                              |        |        |        |        |
|   | % |                              |        |        |        |        |
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|   | r |                              |        |        |        |        |
|   | 1 |                              |        |        |        |        |
|   | m |                              |        |        |        |        |
|   | i |                              |        |        |        |        |
|   | n |                              |        |        |        |        |
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|   | ? |                              |        |        |        |        |
+---+---+------------------------------+--------+--------+--------+--------+
| # | # |                              |  Y   |  Y   |  Y   |  Y   |
| # | # |                              | N      | N      | N      | N      |
| # | # |                              |        |        |        |        |
| # | # |                              |        |        |        |        |
| # | # |                              |        |        |        |        |
| # | # |                              |        |        |        |        |
|   |   |                              |        |        |        |        |
| 2 | I |                              |        |        |        |        |
|   | s |                              |        |        |        |        |
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|   | t |                              |        |        |        |        |
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|   |   |                              |        |        |        |        |
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|   | h |                              |        |        |        |        |
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|   |   |                              |        |        |        |        |
|   | d |                              |        |        |        |        |
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|   | l |                              |        |        |        |        |
|   | i |                              |        |        |        |        |
|   | v |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | r |                              |        |        |        |        |
|   | y |                              |        |        |        |        |
|   |   |                              |        |        |        |        |
|   | p |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | r |                              |        |        |        |        |
|   | s |                              |        |        |        |        |
|   | o |                              |        |        |        |        |
|   | n |                              |        |        |        |        |
|   | ? |                              |        |        |        |        |
+---+---+------------------------------+--------+--------+--------+--------+
| # | N |                              |        |        |        |        |
| # | o |                              |        |        |        |        |
| # | t |                              |        |        |        |        |
| # | e |                              |        |        |        |        |
| # | s |                              |        |        |        |        |
| # | : |                              |        |        |        |        |
|   |   |                              |        |        |        |        |
| 3 |   |                              |        |        |        |        |
+---+---+------------------------------+--------+--------+--------+--------+
| * | * |                              | **Tank | **Tank | **Tank | **Tank |
| * | * |                              | #1**   | #2**   | #3**   | #4**   |
| * | * |                              |        |        |        |        |
| D | A |                              |        |        |        |        |
| . | u |                              |        |        |        |        |
| * | t |                              |        |        |        |        |
| * | o |                              |        |        |        |        |
| * | m |                              |        |        |        |        |
|   | a |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | i |                              |        |        |        |        |
|   | c |                              |        |        |        |        |
|   | S |                              |        |        |        |        |
|   | h |                              |        |        |        |        |
|   | u |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | o |                              |        |        |        |        |
|   | f |                              |        |        |        |        |
|   | f |                              |        |        |        |        |
|   | D |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | v |                              |        |        |        |        |
|   | i |                              |        |        |        |        |
|   | c |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | * |                              |        |        |        |        |
|   | * |                              |        |        |        |        |
|   | * |                              |        |        |        |        |
+---+---+------------------------------+--------+--------+--------+--------+
| 1 | I |                              |  Y   |  Y   |  Y   |  Y   |
|   | s |                              | N      | N      | N      | N      |
|   | t |                              |        |        |        |        |
|   | h |                              |  Unk  |  Unk  |  Unk  |  Unk  |
|   | e |                              |        |        |        |        |
|   | d |                              |        |        |        |        |
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|   | v |                              |        |        |        |        |
|   | i |                              |        |        |        |        |
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|   | t |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
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|   | a |                              |        |        |        |        |
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|   | m |                              |        |        |        |        |
|   | a |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
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|   | c |                              |        |        |        |        |
|   | a |                              |        |        |        |        |
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|   | l |                              |        |        |        |        |
|   | y |                              |        |        |        |        |
|   | s |                              |        |        |        |        |
|   | h |                              |        |        |        |        |
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|   | h |                              |        |        |        |        |
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|   | a |                              |        |        |        |        |
|   | n |                              |        |        |        |        |
|   | k |                              |        |        |        |        |
|   | i |                              |        |        |        |        |
|   | s |                              |        |        |        |        |
|   | 9 |                              |        |        |        |        |
|   | 5 |                              |        |        |        |        |
|   | % |                              |        |        |        |        |
|   | f |                              |        |        |        |        |
|   | u |                              |        |        |        |        |
|   | l |                              |        |        |        |        |
|   | l |                              |        |        |        |        |
|   | o |                              |        |        |        |        |
|   | r |                              |        |        |        |        |
|   | b |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | f |                              |        |        |        |        |
|   | o |                              |        |        |        |        |
|   | r |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | f |                              |        |        |        |        |
|   | i |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | i |                              |        |        |        |        |
|   | n |                              |        |        |        |        |
|   | g |                              |        |        |        |        |
|   | s |                              |        |        |        |        |
|   | a |                              |        |        |        |        |
|   | r |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | x |                              |        |        |        |        |
|   | p |                              |        |        |        |        |
|   | o |                              |        |        |        |        |
|   | s |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | d |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | o |                              |        |        |        |        |
|   | f |                              |        |        |        |        |
|   | u |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | l |                              |        |        |        |        |
|   | ? |                              |        |        |        |        |
+---+---+------------------------------+--------+--------+--------+--------+
| 2 | N |                              |        |        |        |        |
|   | o |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | s |                              |        |        |        |        |
|   | : |                              |        |        |        |        |
+---+---+------------------------------+--------+--------+--------+--------+
| * | * |                              | **Tank | **Tank | **Tank | **Tank |
| * | * |                              | #1**   | #2**   | #3**   | #4**   |
| * | * |                              |        |        |        |        |
| E | B |                              |        |        |        |        |
| . | a |                              |        |        |        |        |
| * | l |                              |        |        |        |        |
| * | l |                              |        |        |        |        |
| * | F |                              |        |        |        |        |
|   | l |                              |        |        |        |        |
|   | o |                              |        |        |        |        |
|   | a |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | V |                              |        |        |        |        |
|   | a |                              |        |        |        |        |
|   | l |                              |        |        |        |        |
|   | v |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | * |                              |        |        |        |        |
|   | * |                              |        |        |        |        |
|   | * |                              |        |        |        |        |
+---+---+------------------------------+--------+--------+--------+--------+
| 1 | I |                              |  Y   |  Y   |  Y   |  Y   |
|   | s |                              | N      | N      | N      | N      |
|   | t |                              |        |        |        |        |
|   | h |                              |  Unk  |  Unk  |  Unk  |  Unk  |
|   | e |                              |        |        |        |        |
|   | b |                              |        |        |        |        |
|   | a |                              |        |        |        |        |
|   | l |                              |        |        |        |        |
|   | l |                              |        |        |        |        |
|   | f |                              |        |        |        |        |
|   | l |                              |        |        |        |        |
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|   | a |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | v |                              |        |        |        |        |
|   | a |                              |        |        |        |        |
|   | l |                              |        |        |        |        |
|   | v |                              |        |        |        |        |
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|   | t |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | o |                              |        |        |        |        |
|   | r |                              |        |        |        |        |
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|   | s |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | r |                              |        |        |        |        |
|   | i |                              |        |        |        |        |
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|   | t |                              |        |        |        |        |
|   | p |                              |        |        |        |        |
|   | r |                              |        |        |        |        |
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|   | d |                              |        |        |        |        |
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|   | t |                              |        |        |        |        |
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|   | l |                              |        |        |        |        |
|   | o |                              |        |        |        |        |
|   | w |                              |        |        |        |        |
|   | w |                              |        |        |        |        |
|   | h |                              |        |        |        |        |
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|   | t |                              |        |        |        |        |
|   | h |                              |        |        |        |        |
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|   | t |                              |        |        |        |        |
|   | a |                              |        |        |        |        |
|   | n |                              |        |        |        |        |
|   | k |                              |        |        |        |        |
|   | i |                              |        |        |        |        |
|   | s |                              |        |        |        |        |
|   | 9 |                              |        |        |        |        |
|   | 0 |                              |        |        |        |        |
|   | % |                              |        |        |        |        |
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|   | l |                              |        |        |        |        |
|   | l |                              |        |        |        |        |
|   | o |                              |        |        |        |        |
|   | r |                              |        |        |        |        |
|   | a |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | l |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | a |                              |        |        |        |        |
|   | s |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | 3 |                              |        |        |        |        |
|   | 0 |                              |        |        |        |        |
|   | m |                              |        |        |        |        |
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|   | n |                              |        |        |        |        |
|   | u |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | s |                              |        |        |        |        |
|   | p |                              |        |        |        |        |
|   | r |                              |        |        |        |        |
|   | i |                              |        |        |        |        |
|   | o |                              |        |        |        |        |
|   | r |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | o |                              |        |        |        |        |
|   | o |                              |        |        |        |        |
|   | v |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | r |                              |        |        |        |        |
|   | f |                              |        |        |        |        |
|   | i |                              |        |        |        |        |
|   | l |                              |        |        |        |        |
|   | l |                              |        |        |        |        |
|   | ? |                              |        |        |        |        |
+---+---+------------------------------+--------+--------+--------+--------+
| 2 | N |                              |        |        |        |        |
|   | o |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | s |                              |        |        |        |        |
|   | : |                              |        |        |        |        |
+---+---+------------------------------+--------+--------+--------+--------+
| * | * |                              | **Tank | **Tank | **Tank | **Tank |
| * | * |                              | #1**   | #2**   | #3**   | #4**   |
| * | * |                              |        |        |        |        |
| F | V |                              |        |        |        |        |
| . | e |                              |        |        |        |        |
| * | n |                              |        |        |        |        |
| * | t |                              |        |        |        |        |
| * | W |                              |        |        |        |        |
|   | h |                              |        |        |        |        |
|   | i |                              |        |        |        |        |
|   | s |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | l |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | * |                              |        |        |        |        |
|   | * |                              |        |        |        |        |
|   | * |                              |        |        |        |        |
+---+---+------------------------------+--------+--------+--------+--------+
| 1 | I |                              |  Y   |  Y   |  Y   |  Y   |
|   | s |                              | N      | N      | N      | N      |
|   | t |                              |        |        |        |        |
|   | h |                              |  Unk  |  Unk  |  Unk  |  Unk  |
|   | e |                              |        |        |        |        |
|   | v |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | n |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | a |                              |        |        |        |        |
|   | l |                              |        |        |        |        |
|   | a |                              |        |        |        |        |
|   | r |                              |        |        |        |        |
|   | m |                              |        |        |        |        |
|   | s |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | o |                              |        |        |        |        |
|   | a |                              |        |        |        |        |
|   | c |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | i |                              |        |        |        |        |
|   | v |                              |        |        |        |        |
|   | a |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | a |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | 9 |                              |        |        |        |        |
|   | 0 |                              |        |        |        |        |
|   | % |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | a |                              |        |        |        |        |
|   | n |                              |        |        |        |        |
|   | k |                              |        |        |        |        |
|   | c |                              |        |        |        |        |
|   | a |                              |        |        |        |        |
|   | p |                              |        |        |        |        |
|   | a |                              |        |        |        |        |
|   | c |                              |        |        |        |        |
|   | i |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | y |                              |        |        |        |        |
|   | ? |                              |        |        |        |        |
+---+---+------------------------------+--------+--------+--------+--------+
| 2 | N |                              |        |        |        |        |
|   | o |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | s |                              |        |        |        |        |
|   | : |                              |        |        |        |        |
+---+---+------------------------------+--------+--------+--------+--------+
| * | * |                              |        |        |        |        |
| * | * |                              |        |        |        |        |
| * | * |                              |        |        |        |        |
| G | M |                              |        |        |        |        |
| . | e |                              |        |        |        |        |
| * | a |                              |        |        |        |        |
| * | s |                              |        |        |        |        |
| * | u |                              |        |        |        |        |
|   | r |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | m |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | n |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | * |                              |        |        |        |        |
|   | * |                              |        |        |        |        |
|   | * |                              |        |        |        |        |
+---+---+------------------------------+--------+--------+--------+--------+
| 1 | D |                              |  Y   |  Y   |  Y   |  Y   |
|   | o |                              | N      | N      | N      | N      |
|   | r |                              |        |        |        |        |
|   | e |                              |  NR  |  NR  |  NR  |  NR  |
|   | c |                              | RR     | RR     | RR     | RR     |
|   | o |                              |        |        |        |        |
|   | r |                              |        |        |        |        |
|   | d |                              |        |        |        |        |
|   | s |                              |        |        |        |        |
|   | i |                              |        |        |        |        |
|   | n |                              |        |        |        |        |
|   | d |                              |        |        |        |        |
|   | i |                              |        |        |        |        |
|   | c |                              |        |        |        |        |
|   | a |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | h |                              |        |        |        |        |
|   | a |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | r |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | g |                              |        |        |        |        |
|   | u |                              |        |        |        |        |
|   | l |                              |        |        |        |        |
|   | a |                              |        |        |        |        |
|   | r |                              |        |        |        |        |
|   | a |                              |        |        |        |        |
|   | n |                              |        |        |        |        |
|   | d |                              |        |        |        |        |
|   | s |                              |        |        |        |        |
|   | u |                              |        |        |        |        |
|   | f |                              |        |        |        |        |
|   | f |                              |        |        |        |        |
|   | i |                              |        |        |        |        |
|   | c |                              |        |        |        |        |
|   | i |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | n |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | m |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | a |                              |        |        |        |        |
|   | s |                              |        |        |        |        |
|   | u |                              |        |        |        |        |
|   | r |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | m |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | n |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | s |                              |        |        |        |        |
|   | a |                              |        |        |        |        |
|   | r |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | c |                              |        |        |        |        |
|   | o |                              |        |        |        |        |
|   | n |                              |        |        |        |        |
|   | d |                              |        |        |        |        |
|   | u |                              |        |        |        |        |
|   | c |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | d |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | o |                              |        |        |        |        |
|   | a |                              |        |        |        |        |
|   | v |                              |        |        |        |        |
|   | o |                              |        |        |        |        |
|   | i |                              |        |        |        |        |
|   | d |                              |        |        |        |        |
|   | o |                              |        |        |        |        |
|   | v |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | r |                              |        |        |        |        |
|   | f |                              |        |        |        |        |
|   | i |                              |        |        |        |        |
|   | l |                              |        |        |        |        |
|   | l |                              |        |        |        |        |
|   | ? |                              |        |        |        |        |
+---+---+------------------------------+--------+--------+--------+--------+
| 2 | N |                              |        |        |        |        |
|   | o |                              |        |        |        |        |
|   | t |                              |        |        |        |        |
|   | e |                              |        |        |        |        |
|   | s |                              |        |        |        |        |
|   | : |                              |        |        |        |        |
+---+---+------------------------------+--------+--------+--------+--------+

# 

# IX. Stage I and II Vapor Recovery

<table>
<colgroup>
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 43%" />
<col style="width: 1%" />
<col style="width: 11%" />
<col style="width: 1%" />
<col style="width: 9%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 11%" />
<col style="width: 1%" />
<col style="width: 11%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="3"><em><strong>A.</strong></em></td>
<td colspan="11"><em><strong>Vapor Recovery Status</strong></em></td>
</tr>
<tr class="even">
<td colspan="3">1</td>
<td>Is Stage I vapor recovery installed at this facility?</td>
<td colspan="10"> Y  N</td>
</tr>
<tr class="odd">
<td colspan="3">2</td>
<td>Type of Stage I vapor recovery system:</td>
<td colspan="10"> Coaxial  Dual point</td>
</tr>
<tr class="even">
<td colspan="3">1</td>
<td colspan="5">Did gasoline throughput of the facility exceed 400,000
gallons over the last calendar year</td>
<td colspan="6"> Y  N</td>
</tr>
<tr class="odd">
<td colspan="3">2</td>
<td colspan="5"><blockquote>
<p>Was it the first time throughput exceeded 400,000 gallons?</p>
</blockquote></td>
<td colspan="6"> Y  N</td>
</tr>
<tr class="even">
<td colspan="3">3</td>
<td colspan="5">How many gasoline vent pipes are at this facility?</td>
<td colspan="6"></td>
</tr>
<tr class="odd">
<td colspan="3">4</td>
<td colspan="5">How many gasoline dispensers are at this facility?</td>
<td colspan="6"></td>
</tr>
<tr class="even">
<td colspan="3">5</td>
<td colspan="5">How many gasoline nozzles are at this facility?</td>
<td colspan="6"></td>
</tr>
<tr class="odd">
<td colspan="3">6</td>
<td colspan="5">Does the facility receive all gasoline deliveries from
account trucks?</td>
<td colspan="6"> Y  N  Unk</td>
</tr>
<tr class="even">
<td colspan="3"><em><strong>B.</strong></em></td>
<td><em><strong>Stage I Vapor Recovery Equipment
Condition</strong></em></td>
<td colspan="2"><strong>Tank #1</strong></td>
<td colspan="4"><strong>Tank #2</strong></td>
<td colspan="2"><strong>Tank #3</strong></td>
<td colspan="2"><strong>Tank #4</strong></td>
</tr>
<tr class="odd">
<td colspan="3">1</td>
<td>Are swivel/rotatable fill adapters installed?</td>
<td colspan="2"> Y  N</td>
<td colspan="4"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td colspan="3">2</td>
<td>Are locking clamps installed?</td>
<td colspan="2"> Y  N</td>
<td colspan="4"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td colspan="3">3</td>
<td><blockquote>
<p>Are adapters and locking clamps tight?</p>
</blockquote></td>
<td colspan="2"> Y  N</td>
<td colspan="4"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td colspan="3">4</td>
<td>Do all fill caps make a tight seal on the fill adaptor (i.e., fill
cap can't be rotated by hand)?</td>
<td colspan="2"> Y  N</td>
<td colspan="4"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td colspan="3">5</td>
<td>Does vapor adapter/poppet valve close tight (free from vapor
releases)? [Dual-point systems]</td>
<td colspan="2"> Y  N</td>
<td colspan="4"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td colspan="3">6</td>
<td>Does poppet cap move easily? [Dual-point systems]</td>
<td colspan="2"> Y  N</td>
<td colspan="4"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td colspan="3">7</td>
<td>Is the vapor cover in good condition?</td>
<td colspan="2"> Y  N</td>
<td colspan="4"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="even">
<td colspan="3">8</td>
<td>Is the vapor cover color-coded orange?</td>
<td colspan="2"> Y  N</td>
<td colspan="4"> Y  N</td>
<td colspan="2"> Y  N</td>
<td colspan="2"> Y  N</td>
</tr>
<tr class="odd">
<td colspan="3">9</td>
<td>Are pressure/vacuum (P/V) vent valves installed on all gasoline UST
vents at the facility?</td>
<td colspan="10"> Y  N</td>
</tr>
<tr class="even">
<td colspan="3">10</td>
<td><blockquote>
<p>If no, identify the number of vents without proper valves</p>
</blockquote></td>
<td colspan="10"></td>
</tr>
<tr class="odd">
<td colspan="3">11</td>
<td><blockquote>
<p>Are there any signs that the P/V vent valves <strong><u>are
not</u></strong> intact?</p>
</blockquote></td>
<td colspan="10"> Y  N</td>
</tr>
<tr class="even">
<td colspan="3">12</td>
<td><blockquote>
<p>Is the pressure setting visible on any of the valves?</p>
</blockquote></td>
<td colspan="10"> Y  N</td>
</tr>
<tr class="odd">
<td colspan="3">13</td>
<td><blockquote>
<p>If yes, is the pressure setting correct for those valves?</p>
</blockquote></td>
<td colspan="10"> Y  N</td>
</tr>
<tr class="even">
<td colspan="3">14</td>
<td>If any vents have P/V valve compliance issues, please note which
vents have issues.</td>
<td colspan="10"></td>
</tr>
<tr class="odd">
<td colspan="2"><em><strong>C.</strong></em></td>
<td colspan="12"><em><strong>Stage II Vapor Recovery
Status</strong></em></td>
</tr>
<tr class="even">
<td colspan="2">1</td>
<td colspan="2">Is Stage II vapor recovery required at the
facility?</td>
<td colspan="10"> Y  N</td>
</tr>
<tr class="odd">
<td colspan="2">2</td>
<td colspan="2">Is Stage II vapor recovery installed?</td>
<td colspan="10"> Y  N</td>
</tr>
<tr class="even">
<td colspan="2">3</td>
<td colspan="2"><blockquote>
<p>Which type of Stage II system is installed? [check all that
apply]</p>
</blockquote></td>
<td colspan="10"><ul>
<li><p>Vapor Balance</p></li>
<li><p>Vacuum Assist</p></li>
</ul></td>
</tr>
<tr class="odd">
<td colspan="2">4</td>
<td colspan="2"><blockquote>
<p>If vacuum assist is installed, which manufacturer made the system?
[check all that apply]</p>
</blockquote></td>
<td colspan="10"><ul>
<li><p>Gilbarco</p></li>
<li><p>Wayne Vac</p></li>
<li><p>Healy</p></li>
<li><p>Other</p></li>
</ul></td>
</tr>
<tr class="even">
<td colspan="2">5</td>
<td colspan="2"><blockquote>
<p>If other, please specify:</p>
</blockquote></td>
<td colspan="10"></td>
</tr>
<tr class="odd">
<td><em><strong>D.</strong></em></td>
<td colspan="8"><em><strong>Stage II Vapor Recovery
Performance</strong></em></td>
<td colspan="5"></td>
</tr>
<tr class="even">
<td><p id="section-7" class="heading">1</p></td>
<td colspan="8"><p
id="are-instructions-for-the-proper-dispensing-of-gasoline-with-the-stage-ii-system-including-a-warning-not-to-top-off-displayed-in-a-conspicuous-location"
class="heading">Are instructions for the proper dispensing of gasoline
with the Stage II system, including a warning not to top off, displayed
in a conspicuous location?</p></td>
<td colspan="5"> Y  N</td>
</tr>
<tr class="odd">
<td>2</td>
<td colspan="8">Are all nozzles CARB certified?</td>
<td colspan="5"> Y  N  RN</td>
</tr>
<tr class="even">
<td>3</td>
<td colspan="8">If no, how many nozzles are not CARB certified?</td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td>5</td>
<td colspan="8">Are all hoses CARB certified?</td>
<td colspan="5"> Y  N  RN</td>
</tr>
<tr class="even">
<td>6</td>
<td colspan="8">If no, how many hoses are not CARB certified?</td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td>8</td>
<td colspan="8">Are all breakaways CARB certified?</td>
<td colspan="5"> Y  N  RN</td>
</tr>
<tr class="even">
<td>9</td>
<td colspan="8">If no, how many breakaways are not CARB certified?</td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td>11</td>
<td colspan="8">Are all face plates/vapor escape guards intact?</td>
<td colspan="5"> Y  N</td>
</tr>
<tr class="even">
<td>12</td>
<td colspan="8">If no, how many face plates/vapor guards are not
intact?</td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td>13</td>
<td colspan="8">Are all hoses intact?</td>
<td colspan="5"> Y  N</td>
</tr>
<tr class="even">
<td>14</td>
<td colspan="8">If no, how many hoses are not intact?</td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td>15</td>
<td colspan="8">Are all hose retractors intact (vapor balance)?</td>
<td colspan="5"> Y  N</td>
</tr>
<tr class="even">
<td>16</td>
<td colspan="8">If no, how many hose retractors are not intact?</td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td>17</td>
<td colspan="8">Are nozzle spouts tight?</td>
<td colspan="5"> Y  N</td>
</tr>
<tr class="even">
<td>18</td>
<td colspan="8">If no, how many nozzle spouts are not tight?</td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td>19</td>
<td colspan="8">Are all nozzle bellows intact (vapor balance)?</td>
<td colspan="5"> Y  N</td>
</tr>
<tr class="even">
<td>20</td>
<td colspan="8">If no, how many nose bellows are not intact?</td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td>21</td>
<td colspan="8">Are all clamps in place on bellows (vapor balance)?</td>
<td colspan="5"> Y  N</td>
</tr>
<tr class="even">
<td>22</td>
<td colspan="8">If no, how many bellows do not have clamps in
place?</td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td>23</td>
<td colspan="8">Are all hoses prevented from contact with the ground
(vapor balance)?</td>
<td colspan="5"> Y  N</td>
</tr>
<tr class="even">
<td>24</td>
<td colspan="8">If no, how many hoses are not prevented from contact
with the ground?</td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td>25</td>
<td colspan="8">Are all loops a 10" loop or less (vapor balance)?</td>
<td colspan="5"> Y  N</td>
</tr>
<tr class="even">
<td>26</td>
<td colspan="8">If no, how many loops are not 10" or less?</td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td>27</td>
<td colspan="8">Are any nozzles out of service or tagged out?</td>
<td colspan="5"> Y  N</td>
</tr>
<tr class="even">
<td>28</td>
<td colspan="8">If yes, how many nozzles are out of service or tagged
out?</td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td>29</td>
<td colspan="13">Notes: [e.g., specific items that have problems]:</td>
</tr>
<tr class="even">
<td><p id="c." class="heading"><em><strong>C.</strong></em></p></td>
<td colspan="13"><p
id="stage-ii-vapor-recovery-training-inspections-and-recordkeeping"
class="heading"><em><strong>Stage II Vapor Recovery Training,
Inspections and Recordkeeping</strong></em></p></td>
</tr>
<tr class="odd">
<td>1</td>
<td colspan="4">Do records indicate that the Stage II system is visually
inspected every week?</td>
<td colspan="9"> Y  N</td>
</tr>
<tr class="even">
<td>2</td>
<td colspan="4">What is the date of the most recent visual system
inspection?</td>
<td colspan="9"> Y  N</td>
</tr>
<tr class="odd">
<td>3</td>
<td colspan="4">Are records of the last 52 weeks of Stage II system
visual inspections maintained at the facility?</td>
<td colspan="9"><p> Y  N</p>
<p> NR  RR</p></td>
</tr>
<tr class="even">
<td>4</td>
<td colspan="4">Is there evidence that defective parts of the Stage II
systems found during weekly inspections were removed from service until
they were repaired or replaced?</td>
<td colspan="9"> Y  N</td>
</tr>
<tr class="odd">
<td>5</td>
<td colspan="4">Are records of repairs kept for at least 3 years?</td>
<td colspan="9"><p> Y  N</p>
<p> NR  RR</p></td>
</tr>
<tr class="even">
<td>6</td>
<td colspan="4">Has annual maintenance been performed this calendar
year?</td>
<td colspan="9"><p> Y  N</p>
<p> NR</p></td>
</tr>
<tr class="odd">
<td>7</td>
<td colspan="4">If yes, was it conducted on or before May 15?</td>
<td colspan="9"> Y  N</td>
</tr>
<tr class="even">
<td>8</td>
<td colspan="4">Has a pressure decay test been performed this calendar
year?</td>
<td colspan="9"><p> Y  N</p>
<p> NR</p></td>
</tr>
<tr class="odd">
<td>9</td>
<td colspan="4">If yes, was it conducted on or before May 15?</td>
<td colspan="9"> Y  N</td>
</tr>
<tr class="even">
<td>10</td>
<td colspan="4"><blockquote>
<p>If yes, was the test successful?</p>
</blockquote></td>
<td colspan="9"> Y  N</td>
</tr>
<tr class="odd">
<td>11</td>
<td colspan="4"><blockquote>
<p>If no, do records indicate a more recent successful test has been
conducted?</p>
</blockquote></td>
<td colspan="9"> Y  N</td>
</tr>
<tr class="even">
<td><p id="section-8" class="heading">12</p></td>
<td colspan="4"><p
id="has-apcd-received-an-annual-maintenance-form-or-pressure-decay-test-report-from-the-facility"
class="heading">Has APCD received an annual maintenance form or pressure
decay test report from the facility?</p></td>
<td colspan="9"> Y  N</td>
</tr>
<tr class="odd">
<td><p id="section-9" class="heading">13</p></td>
<td colspan="4"><p
id="if-yes-was-it-received-on-or-before-june-15-of-this-calendar-year"
class="heading">If yes, was it received on or before June 15 of this
calendar year? </p></td>
<td colspan="9"> Y  N</td>
</tr>
<tr class="even">
<td><p id="d." class="heading"><em><strong>D.</strong></em></p></td>
<td colspan="13"><p id="stage-ii-vapor-recovery-testing"
class="heading"><em><strong>Stage II Vapor Recovery
Testing</strong></em></p></td>
</tr>
<tr class="odd">
<td>1</td>
<td colspan="4">Do records indicate a pressure decay test performed
within the last 5 years?</td>
<td colspan="9"><p> Y  N</p>
<p> NR  RR</p></td>
</tr>
<tr class="even">
<td>2</td>
<td colspan="4">Do records indicate a 10-gallon per minute test
performed within the last 5 years?</td>
<td colspan="9"><p> Y  N</p>
<p> NR  RR</p></td>
</tr>
<tr class="odd">
<td>3</td>
<td colspan="4">Do records indicate air to liquid ratio test performed
within the last 5 years (only relevant for vacuum assist systems)?</td>
<td colspan="9"><p> Y  N</p>
<p> NR  RR</p></td>
</tr>
<tr class="even">
<td>4</td>
<td colspan="4">Is there a record of the last Stage II system
re-test?</td>
<td colspan="9"><p> Y  N</p>
<p> NR  RR</p></td>
</tr>
<tr class="odd">
<td>5</td>
<td colspan="4"><blockquote>
<p>If yes, what is the date of the last Stage II system re-test?</p>
</blockquote></td>
<td colspan="9"> Y  N</td>
</tr>
<tr class="even">
<td>6</td>
<td colspan="4">Have there been any modifications or incidents at the
facility since the last test that might require re-testing of the Stage
II system? [Check all that apply.]</td>
<td colspan="2"><ul>
<li><p>New dispenser</p></li>
<li><p>Replaced dispenser</p></li>
<li><p>Stage II system change</p></li>
</ul></td>
<td colspan="4"><ul>
<li><p>UST repair</p></li>
<li><p>UST replacement</p></li>
</ul></td>
<td colspan="2"><ul>
<li><p>Underground piping repair</p></li>
<li><p>Underground piping replacement</p></li>
</ul></td>
<td><ul>
<li><p>Significant damage to any Stage II component</p></li>
<li><p>Other</p></li>
</ul></td>
</tr>
<tr class="odd">
<td>7</td>
<td colspan="13">If other, please specify:</td>
</tr>
<tr class="even">
<td>8</td>
<td colspan="13">Notes:</td>
</tr>
</tbody>
</table>

# X. Underground Injection Control

+---+---------------------------------------------------------+----------+
| * | ***UIC Status***                                        |          |
| * |                                                         |          |
| * |                                                         |          |
| A |                                                         |          |
| . |                                                         |          |
| * |                                                         |          |
| * |                                                         |          |
| * |                                                         |          |
+---+---------------------------------------------------------+----------+
| 1 | Does the facility have a floor drain?                   |  Y  N  |
+---+---------------------------------------------------------+----------+
| * | ***UIC Management***                                    |          |
| * |                                                         |          |
| * |                                                         |          |
| B |                                                         |          |
| . |                                                         |          |
| * |                                                         |          |
| * |                                                         |          |
| * |                                                         |          |
+---+---------------------------------------------------------+----------+
| 1 | Is there an oil/water separator in the floor drain?     |  Y  N  |
+---+---------------------------------------------------------+----------+
| 2 | Is vehicle or machine maintenance performed near the    |  Y  N  |
|   | floor drain?                                            |          |
+---+---------------------------------------------------------+----------+
| 3 | Does vehicle or machine washing occur near the floor    |  Y  N  |
|   | drain?                                                  |          |
+---+---------------------------------------------------------+----------+
| 4 | Are chemicals stored near the floor drain?              |  Y  N  |
+---+---------------------------------------------------------+----------+
| 5 | > If yes, are chemicals surrounded by secondary         |  Y  N  |
|   | > containment?                                          |          |
+---+---------------------------------------------------------+----------+
| 6 | Do signs near the floor drain explain prohibition on    |  Y  N  |
|   | discharges of chemicals and vehicle fluids into the     |          |
|   | floor drain?                                            |          |
+---+---------------------------------------------------------+----------+
| 7 | Does the facility appear equipped for dry cleanup of    |  Y  N  |
|   | spills?                                                 |          |
+---+---------------------------------------------------------+----------+
| * | ***UIC Discharges and Permitting***                     |          |
| * |                                                         |          |
| * |                                                         |          |
| C |                                                         |          |
| . |                                                         |          |
| * |                                                         |          |
| * |                                                         |          |
| * |                                                         |          |
+---+---------------------------------------------------------+----------+
| 1 | Does the floor drain discharge on site? (e.g., drywell, |  Y  N  |
|   | septic system)                                          |          |
+---+---------------------------------------------------------+----------+
| 2 | Does the floor drain discharge to the environment?      |  Y  N  |
|   | (e.g., daylight, surface waters, swale, stormwater      |          |
|   | detention pond, or neighbor's property)                 |          |
+---+---------------------------------------------------------+----------+
| 3 | Does the floor drain discharge to a holding tank?       |  Y  N  |
+---+---------------------------------------------------------+----------+
| 4 | Does the floor drain discharge to municipal sewer?      |  Y  N  |
+---+---------------------------------------------------------+----------+
| 5 | > If yes, does the facility have a wastewater permit?   |  Y  N  |
+---+---------------------------------------------------------+----------+
| 6 | > What is the permit number?                            |          |
+---+---------------------------------------------------------+----------+
| 7 | Is the discharge from the floor drain registered with   |  Y  N  |
|   | the UIC program?                                        |          |
+---+---------------------------------------------------------+----------+
| * | ***UIC Notes***                                         |          |
| * |                                                         |          |
| * |                                                         |          |
| D |                                                         |          |
| . |                                                         |          |
| * |                                                         |          |
| * |                                                         |          |
| * |                                                         |          |
+---+---------------------------------------------------------+----------+
| 1 | Notes:                                                  |          |
+---+---------------------------------------------------------+----------+

# XI. Hazardous Fuel-Contaminated Waste

+---+--------------------------------------------------------+----------+
| * | ***Hazardous Fuel-Contaminated Waste Generation        |          |
| * | Information***                                         |          |
| * |                                                        |          |
| A |                                                        |          |
| . |                                                        |          |
| * |                                                        |          |
| * |                                                        |          |
| * |                                                        |          |
+---+--------------------------------------------------------+----------+
| 1 | What is the facility\'s hazardous waste generator      |  CEG   |
|   | status?                                                | SQG      |
|   |                                                        |          |
|   |                                                        |  LQG    |
+---+--------------------------------------------------------+----------+
| 2 | What is the facility's generator ID number?            |          |
+---+--------------------------------------------------------+----------+
| 3 | Does the facility use the fuel-to-fuel exemption for   |  Y  N  |
|   | any of its fuel-contaminated waste?                    |          |
+---+--------------------------------------------------------+----------+
| 4 | How much hazardous fuel-contaminated waste did the     |          |
|   | facility generate in the previous 12 months (in        |          |
|   | pounds)?                                               |          |
+---+--------------------------------------------------------+----------+
| 5 | Does the facility generate any kinds of hazardous      |  S  A  |
|   | waste besides fuel-contaminated waste? \[check all     |          |
|   | that apply\]                                           |  P  O  |
|   |                                                        |          |
|   |                                                        |  J      |
+---+--------------------------------------------------------+----------+
| 6 | If other, please specify:                              |          |
+---+--------------------------------------------------------+----------+
| 7 | Does the facility generate used oil?                   |  Y  N  |
+---+--------------------------------------------------------+----------+
| 8 | If yes, does the facility mix used oil with hazardous  |  Y  N  |
|   | waste?                                                 |          |
+---+--------------------------------------------------------+----------+
| * | ***Hazardous Fuel-Contaminated Waste Determination and |          |
| * | Separation***                                          |          |
| * |                                                        |          |
| B |                                                        |          |
| . |                                                        |          |
| * |                                                        |          |
| * |                                                        |          |
| * |                                                        |          |
+---+--------------------------------------------------------+----------+
| 1 | Has the facility correctly determined which wastes are |          |
|   | hazardous fuel-contaminated wastes? \[I.e., spill      |          |
|   | bucket/sump wastes; tank bottoms; surface spills; and  |          |
|   | rags, absorbents and spill cleanup materials.\]        |          |
+---+--------------------------------------------------------+----------+
| * | ***Hazardous Fuel-Contaminated Waste Storage***        |          |
| * |                                                        |          |
| * |                                                        |          |
| C |                                                        |          |
| . |                                                        |          |
| * |                                                        |          |
| * |                                                        |          |
| * |                                                        |          |
+---+--------------------------------------------------------+----------+
| 1 | Does the facility store all fuel-contaminated wastes   |  Y  N  |
|   | under cover (i.e., protected from precipitation)?      |          |
+---+--------------------------------------------------------+----------+
| 2 | Does the facility store all fuel-contaminated waste on |  Y  N  |
|   | impervious surfaces?                                   |          |
+---+--------------------------------------------------------+----------+
| 3 | Does the facility close all fuel-contaminated waste    |  Y  N  |
|   | containers when not in use?                            |          |
+---+--------------------------------------------------------+----------+
| 4 | Does the facility protect all fuel-contaminated waste  |  Y  N  |
|   | from freezing?                                         |          |
+---+--------------------------------------------------------+----------+
| 5 | Does the facility store all fuel-contaminated wastes   |  Y  N  |
|   | in containers or tanks that are in good condition      |          |
|   | (i.e., no leaks or risk of leaks)?                     |          |
+---+--------------------------------------------------------+----------+
| * | ***Hazardous Fuel-Contaminated Waste Disposal***       |          |
| * |                                                        |          |
| * |                                                        |          |
| D |                                                        |          |
| . |                                                        |          |
| * |                                                        |          |
| * |                                                        |          |
| * |                                                        |          |
+---+--------------------------------------------------------+----------+
| 1 | Do records indicate that the facility disposes of all  |  Y  N  |
|   | fuel-contaminated waste to authorized facilities?      |          |
|   |                                                        |  NR    |
|   |                                                        | RR       |
+---+--------------------------------------------------------+----------+
| * | ***Hazardous Fuel-Contaminated Waste Training***       |          |
| * |                                                        |          |
| * |                                                        |          |
| E |                                                        |          |
| . |                                                        |          |
| * |                                                        |          |
| * |                                                        |          |
| * |                                                        |          |
+---+--------------------------------------------------------+----------+
| 1 | Have employees been trained in fuel-contaminated waste |  Y  N  |
|   | handling?                                              |          |
+---+--------------------------------------------------------+----------+
| * | ***Hazardous Fuel-Contaminated Waste Notes***          |          |
| * |                                                        |          |
| * |                                                        |          |
| F |                                                        |          |
| . |                                                        |          |
| * |                                                        |          |
| * |                                                        |          |
| * |                                                        |          |
+---+--------------------------------------------------------+----------+
| 1 | Notes:                                                 |          |
+---+--------------------------------------------------------+----------+

#  XII. Spills and Releases

+---+-------------------------------------------------+-----------------+
| * | ***Spill Equipment and Training***              |                 |
| * |                                                 |                 |
| * |                                                 |                 |
| A |                                                 |                 |
| . |                                                 |                 |
| * |                                                 |                 |
| * |                                                 |                 |
| * |                                                 |                 |
+---+-------------------------------------------------+-----------------+
| 1 | Does the facility have spill equipment on hand? |  Y  N         |
+---+-------------------------------------------------+-----------------+
| 2 | Does the facility have stickers with DEC        |  Y  N         |
|   | emergency spill number posted? \[BMP\]          |                 |
+---+-------------------------------------------------+-----------------+
| 3 | Have employees been trained on how to deal with |  Y  N         |
|   | spills?                                         |                 |
+---+-------------------------------------------------+-----------------+
| * | ***Releases***                                  |                 |
| * |                                                 |                 |
| * |                                                 |                 |
| B |                                                 |                 |
| . |                                                 |                 |
| * |                                                 |                 |
| * |                                                 |                 |
| * |                                                 |                 |
+---+-------------------------------------------------+-----------------+
| 1 | Is there evidence (physical, visual, or verbal) |  Y  N         |
|   | of fire, explosion, spill or other release?     |                 |
+---+-------------------------------------------------+-----------------+
| 2 | > What was released?                            | -   Hazardous   |
|   |                                                 |     fu          |
|   |                                                 | el-contaminated |
|   |                                                 |     waste       |
|   |                                                 |                 |
|   |                                                 | -   Fuel        |
|   |                                                 |                 |
|   |                                                 | -   Used oil    |
|   |                                                 |                 |
|   |                                                 | -   Universal   |
|   |                                                 |     waste       |
|   |                                                 |                 |
|   |                                                 | -   Other       |
+---+-------------------------------------------------+-----------------+
| 3 | > If other, please specify:                     |                 |
+---+-------------------------------------------------+-----------------+
| 4 | > What is the evidence?                         |                 |
+---+-------------------------------------------------+-----------------+
| 5 | > Has the facility reported any release?        |  Y  N         |
+---+-------------------------------------------------+-----------------+
| 6 | Notes:                                          |                 |
+---+-------------------------------------------------+-----------------+

# XIII. Additional Information

  --------- --------------------------------------------------------------------
  ***A***   ***Additional Notes:***

            
  --------- --------------------------------------------------------------------

# XIV. Certification of Inspection

I hereby certify that on this date the undersigned inspector visited
this facility.

Contact\'s Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Inspector\'s Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_