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Section 10: House Keeping and Monitoring Pipe/Well Inspection 10.a. Facility House Keeping

# 1

Answer (P)ass, (PC), (F)ail or (NA) Facility is clean with no sign of spillage or open containers of oil.

2

ASTs (if present) are clean and properly maintained.

3 4

Pump island area is clean with no indication of surface spillage. Garage area (if present) is maintained with no indication of surface spillage.

House Keeping passes inspection. Questions 1 – 4 are (P) or (PC) or (NA) Note: If the answer to any questions is (F), explain below. List any problems noted during inspection. Note corrections.

10.b. Tank Field Monitoring Pipes

[ ] Applicable [ ] Not Applicable

# 1

Answer (P)ass, (PC), (F)ail or (NA) Storage systems installed after March 15, 1985 have PVC monitoring pipes installed on opposing corners of the tank field.

MP-1

MP-2

MP-3

MP-4

1a.

2

3

4

5

Gasoline storage systems installed after January 26, 2005 +>2,000-gallons or multiple tanks in a shared excavation used to fuel motor vehicles located in HRGUA* have four monitoring pipes (each corner of the tank field). Monitoring pipes are screened to within 2ft. of the surface and the remaining 2ft. being solid pipe and sealed to prevent entrance of surface runoff. Monitoring pipe has liquid-tight cap, protected from traffic with manhole cover and locked or bolted closed. Monitoring pipe cover is clearly marked “monitoring well-do not fill” or identified using API color code symbol. Monitoring pipes checked for the presence of petroleum contamination and if present complete 5a.

5a.

Record product thickness if taken. Record field vapor reading if taken.

Site wells for Facilities located in HRGUA*

Answer (P)ass, (PC), (F)ail or (NA)

6

7

8

9

Facility or immediate neighbor on either side supplied by potable well? Three or more groundwater monitoring wells installed outside of tank excavation area. Monitoring wells have liquid-tight cap, protected from traffic with manhole cover and locked or bolted closed. Groundwater has been sampled within 180 days and sample results available?

(Circle one) Y/N

10

Site potable well has been sampled within 180 days.

Monitoring Pipes and Site Wells Pass Inspection. Questions 1 – 5 and 7 – 10 are (P) or (PC) or (NA) Note: If the answer to any question is (F), explain below. List any problems noted during inspection. Note corrections. *“High Risk Groundwater Use Area” (HRGUA) means all areas served by individual wells. Existing UST systems installed prior to 1/26/05 in Baltimore, Carroll, Cecil, Frederick and Harford counties or New UST systems installed after 1/26/05 in Anne Arundel, Baltimore, Carroll, Cecil, Charles, Calvert, Frederick, Harford, Howard, Montgomery, and Prince George’s

counties.

Comments:

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

Facility I.D.

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