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Section 12: Release Detection (cont’d.)

[ ] Applicable [ ] Not Applicable

Section 12.d. Statistical Inventory Reconciliation Complete this section and Section 11 (Inventory Control) if you use Statistical Inventory Reconciliation (SIR).

Answer (P)ass, (PC), (F)ail for each

tank system.

1

SIR method on NWGLDE* list.

Tank

Pipe

Tank

Pipe

Tank

Pipe

Tank

Pipe

### ## ## #

__

___ A

___

___

___

___

___

___

A

A

A

Tank #___

NA

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NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

2

Method Name: _____________________ Inventory records are submitted to the SIR

vendor within 5 days of the 30 day monitoring period.

2

3

4

a SIR results are received by owner from vendor within 15 days of submittal of data. SIR results indicate sufficient amount of data was used to perform leak check. Existing release detection results show no evidence of a failure for the previous 12 months.

Statistical Inventory Reconciliation (SIR) Passes Inspection. Questions 1 – 4 are all (P) or (PC).

NA

NA

NA

NA

Note: If the answer to any question is (F), explain below. List any problems noted during inspection. Note corrections. *www.nwglde.org (National Work Group on Leak Detection Evaluations)

Comments:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

[ ] Applicable [ ] Not Applicable

Section 12.e. Groundwater Monitoring Answer (P)ass, (PC), (F)ail for each Pipe #___ Pipe #___ Pipe #___ Pip #__ Tank #___ Tank #___ Tank #___ Tank #____ # tank system Groundwater at site is not more than 15 feet from ground surface during inspection. Slotted casing is properly screened across the water table to allow entry of product. Monitoring wells intercept the UST excavation zone or positioned as close as technically feasible. Regulated substance is immiscible in water and has a specific gravity of less than one. Site evaluation report on site and verifies above information and background contamination will not interfere with groundwater monitoring. Attach evaluation cover page. Monitoring device is capable of detecting 1/8 inch of free product and wells are monitored monthly with results recorded. Groundwater Monitoring passes inspection. Questions 1 – 6 are all (P) or (PC) Note: If the answer to any question is (F), please explain below. List any problems noted during inspection. Note corrections. Comments: 1 2 3 4 5 6

Tank #___

______________________________________________________________________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

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

Facility I.D.

_________________

Page 22 of 24 Recycled Paper

Pipe #___

A

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