California Code of Regulations › Title 23 - Waters › Division 3 - State Water Resources Control Board and Regional Water Quality Control Boards › Chapter 16 - Underground Tank Regulations › Appendix XIII - Underground Storage Tank Designated UST Operator Visual Inspection Report

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. FACILITY INFORMATION
CERS ID
Inspection
						  Date
___________________________
Facility Name
___________________________
Facility Address
City
ZIP Code
___________________________
2. DESIGNATED UST OPERATOR INFORMATION
Name of Designated UST Operator
Phone
___________________________
ICC Certification
Certification Expiration
						  Date
___________________________
3. COMPLIANCE ISSUES
Identify by number all compliance issues
				  listed
4. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING
				  INSPECTION
I hereby certify that the visual inspection was
				  performed in compliance with California Code of Regulations, title 23, division
				  3, chapter 16, section
				  2716 and all information provided
				  herein is accurate.
Designated UST Operator Signature
CERS = California Environmental Reporting System, ICC =
				  International Code Council, ID = Identification, NA = Not Applicable, UDC =
				  Under-Dispenser Containment, UST = Underground Storage Tank
5. OWNER/OPERATOR DESCRIPTION OF FOLLOW-UP
				  ACTION
Number the follow up actions to correspond to appropriate
				  compliance issues from Section
				  3.
6. OWNER / OPERATOR ACKNOWLEDGEMENT OF INSPECTION
				  RESULTS
I have reviewed the results of the designated UST
				  operator inspection report and provided a description of the action(s) taken or
				  to be taken to correct any compliance issues discovered.
Name of UST Owner / Operator (print)
___________________________
UST Owner/Operator Signature
Date Signed
___________________________
7. INSPECTION HISTORY
Has each follow-up action of Section
						  3 from the previous Designated
						  UST
Yes
No
NA
Operator Inspection Report been completed
						  appropriately?
[]
[]
[]
(Attach documentation verifying appropriate
						  service to this report.)
8. RELEASE DETECTION ALARM HISTORY
Attach a copy of the alarm history
						  report/log to this
						  report.
Yes
No
NA
Is the monitoring system powered on and in proper
						  operating mode?
[]
[]
Has each alarm since the previous inspection been
						  responded to appropriately?
(Attach documentation verifying appropriate
						  service to this report.)
[]
[]
[]
Have all containment sumps, that have had an alarm
						  since the previous designated UST operator inspection report, been responded to
						  by a qualified service technician?
[]
[]
[]
All answers marked "No" must be described by
						  the designated UST operator in Section
						  3.
9. UST SYSTEM INSPECTION
List below and in Section
				  3 all containment sumps that have
				  had a release detection alarm since the previous Designated UST Operator
				  Inspection Report and have not been responded to by a qualified service
				  technician. Containment sumps listed below require a visual inspection for
				  damage, water, debris, hazardous substance, and proper sensor
				  location.
Is the
containment sump
free of damage,
				  water, debris, and hazardous substances?
Containment Sump
						  ID
Yes
No
Containment
						  Sump ID
Yes
No
___________________________
[]
[]
___________________________
[]
[]
___________________________
[]
[]
___________________________
[]
[]
Are all sensors in visually inspected
containment sumps
located to detect a release at the earliest
						  opportunity?
[]
[]
Is the
spill containment
free of damage,
				  water, debris, and hazardous substances? Is the fill pipe free of obstructions?
				  Is fill cap securely on the fill pipe?
Spill Containment
						  ID
Yes
No
Spill
						  Containment
						  ID
Yes
No
___________________________
[]
[]
___________________________
[]
[]
___________________________
[]
[]
___________________________
[]
[]
___________________________
[]
[]
___________________________
[]
[]
___________________________
[]
[]
___________________________
[]
[]
Is the
UDC
free of damage, water,
				  debris, and hazardous substances and all sensors located to detect a release at
				  the earliest opportunity?
[] No UDC(s) at this facility
UDC
						  ID
Yes
No
UDC
						  ID
Yes
No
___________________________
[]
[]
___________________________
[]
[]
___________________________
[]
[]
___________________________
[]
[]
___________________________
[]
[]
___________________________
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[]
___________________________
[]
[]
___________________________
[]
[]
___________________________
[]
[]
___________________________
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___________________________
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[]
___________________________
[]
[]
___________________________
[]
[]
___________________________
[]
[]
[]Mechanical float mechanisms used in UDCs.
All answers marked "No" must be described by the
				  designated UST operator in Seciton 3.
10. TESTING AND
						  MAINTENANCE
Yes
No
NA
Date
						  last performed
Has monitoring system certification been completed
						  within the past 12 months?
[]
[]
Has spill container testing been completed within the
						  past 12 months?
[]
[]
Has overfill prevention equipment inspection been
						  completed within the past 36 months?
[]
[]
[]
Has secondary containment testing been completed within
						  the past 36 months?
[]
[]
[]
Has tank tightness testing been completed within
						  required timeframes?
[]
[]
[]
Has line tightness testing been completed within the
						  required timeframes?
[]
[]
[]
Other Test / Maintenance:
[]
[]
[]
Other Test / Maintenance:
[]
[]
[]
Other Test / Maintenance:
[]
[]
[]
11. FACILITY EMPLOYEE
						  TRAINING
Yes
No
Have all individuals performing facility employee
						  duties received the required facility employee training within the past 12
						  months?
[]
[]
13. COMMENTS
This section may be used to record comments or
				  observations that are not current compliance deficiencies.
All answers marked "No" must be described by the
				  designated UST operator in Section
				  3.
1. New
				  Appendix XIII filed 8-27-2018; operative 10-1-2018 (Register 2018, No.
				  35).
2. Repealer and new appendix filed 8-27-2020; operative
				  10-1-2020 (Register 2020, No. 35). Filing deadline specified in Government Code
				  section
				  11349.3(a)
				  extended 60 days pursuant to Executive Order N-40-20 and an additional 60 days
				  pursuant to Executive Order N-66-20.