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MDE Facility ID Number:

Date of Inspection: mm/dd/yyyy

Current UST Registration Certificate on display or available onsite?

All applicable tanks registered?

Site located in High Risk Groundwater Use Area? *

Site or neighbor supplied by a potable Well? * [ ] Yes [ ] No

Owner/Operator has provided approved documentation to demonstrate Financial Responsibility?

[ ] Yes [ ] No

[ ] Yes [ ] No

[ ] Yes [ ] No

[ ] Yes [ ] No If yes, attach FR proof to this form.

Maryland Department of the Environment

Oil Control Program, Suite 620, 1800 Washington Blvd., Baltimore MD 21230-1719 410-537-3442 410-537-3092 (fax) 1-800-633-6101 x3442 http://www.mde.state.md.us

Underground Storage Tank System Compliance Inspection Report

Instructions: Only a person currently certified by the Maryland Department of the Environment in UST Inspection shall complete this report. Detailed instructions on how to complete this form are provided in MDE’s “UST Operations Inspector Reference Handbook,” which is available at: http://www.mde.state.md.us/assets/document/OilControl/USTInspector_Reference_Handbook.pdf. Use a second form for facilities with more than 5 tanks. Type or Print all information with blue or black ink. Section 1: General Information

Facility Name: Location Address: City: Telephone No.:

Owner Name: Mailing Address: City, State, Zip: Telephone No.: Fax No.: E-Mail:

Operator Name: Telephone No.: Fax No.: E-Mail:

Form Number: MDE/WAS/COM.055 Date: April 3, 2007 TTY Users: 800-735-2258

Page 1 of 24 Recycled Paper

Section

Tank #

No

___

Tank #

Tank #

Tank #

Tank #

___

___

___

___

Fill out the following using these codes: P=Pass Inspection, PC=Pass w/corrections,

Status: (Temporarily Out of Use)

(3.)

F=Fail Inspection, NA= Not Applicable

[ ] Yes [ ] No [ ] Yes [ ] No

Inspection Summary Tank System ID Number as listed on MDE UST Registration Form Owner Tank ID # (if different)

(4a.) (4b.) (5a.) (5b.) (6a.) (6b.) (7a.) (7b.)

Piping Construction and Corrosion Protection Tank Construction and Corrosion Protection Tightness Testing Facility House Keeping Tank Field Monitoring Pipes and Site Wells Inventory Control Tank Release Detection Piping Release Detection Inspector and Owner/Operator has signed Addendum Form Used

Containment Sump Inspe Dispenser Inspection Tank Top Inspection Vent Pipe Inspection Spill Prevention Overfill Prevention Stage I Vapor Recovery Stage II Vapor Recovery

ction

(8.)

(11.) (12.) (12.) page 2 and initialed page 24

(8.)

(9.) (10a.) (10b.)

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