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Section 3: Tank Temporarily Closed or Taken Out of Service

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Fill out this section for any tank that is "temporarily closed" or "taken out of service" (empty, out of use). A complete inspection of these tanks is required. This section does not apply to a tank that is currently in use or permanently out of use.

[ ] Applicable [ ] Not Applicable

# 1 2

Answer all (P)ass, (F)ail (PC), or (NA) for each Tank Tank contains less than 1" of product. Tank vented and fill pipe locked.

Tank #

Tank

Tank #

Tank #

Tank #

3 4

Date temp. closed or taken out of service (Month/Day/Year).

UST closed 3 months or more, drain and cap product lines and secure other lines, pumps, and manways (vent line open and operating).

Temporarily Closed Tank(s) passes inspection. Questions 1,2 and 4 are (P) or (PC)

Section 4: Containment Sump and Dispenser Inspection 4.a. Containment Sump Inspection

__

[ ] Applicable [ ] Not Applicable

#

Complete 1 and 8. Answer (P)ass, (PC), (F)ail or (NA) for 2 7 (each tank)

Tank #

Tank #

Tank #

Tank #

Tank #

1

( )Equipped with containment sump

dispenser- tank top - vent riser -

Stage two-condensate pod - Other – Specify in comments -

2

3

4

All containment sumps are clean and free of debris, product, and water. All manway covers and containment sump lids are properly fitted and not in contact with cap, piping, or pump. All containment sumps have no visible cracks, holes, or openings.

5

6

7

8

If sump equipped with liquid sensor the sensor is properly secured and within 1” of sump bottom or meets manufacturer’s specifications. If equipped with double-wall piping, test boot is open to allow product flow to sump. Containment sump has been tested within past 5 years with passing results. Enter Date of last containment sump test.

Containment Sump passes inspection. Questions 2 – 7 are (P) or (PC) Note: If answer to any question is (F), explain below. List any problems noted during inspection. Note corrections.

Comments:

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

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

Facility I.D.

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