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Third Party Underground Storage Tank Inspection - Correspondence - 1 MASSACHUSETTS AVENUE 8/7/2010
i Massachusetts Department of Environmental Protection Underground Storage Tank Program Form UST FP-289 Third Party Underground Storage Tank Inspection Instructions: This form shall be completed by a Third-Party Inspector as defined by 527 CMR 9.02 and in compliance with 527 CMR 9.07(P) SectionInformation Facility Name: Men-imack Valley Oil CO. DEP Facility I Number: 19705 Required Can be looked up at: littp://db.state.ma.tis/deL)/ust/tist!2tlgLyPage.asp Street Address(no P.O. Box): 3 Massachusetts Avenue City: North Andover State MA Zip 1 01845 County: SSCX Phone Number at Facility: (978)683 -3131 Operator Information Name: Torn Markievitz Title: Home Phone: { 978 )683—3131 Fax ( 978 )689—8051 E-mail: Address: 3 Massachusetts Avenue City: North Andover State MA Zip 1 01145 Owner Information Owner Name: Susane O'Brien / PA-rpn3 RCA(-T Y TR 05,r Address: 3 Massachusetts Avenue City: North Andover State MA Zip 01845 County: Ss e x Phone Number: ( 978 )683 -3131 Fax ( 978 )689-8051 E-mail: Federal Employers ID#: 04-6500343 Questions? Contact the MassDEP office at phone: 617-556-1053 Also check the FP-289 FAQ at litti)://wiv�v.itiass.gov/dep/toxies/ust/ Inspector's Initials_1[ Owner/Operator's Initials: Date T —/0 FP-289 (Rev 9/2009)-Page 1 Date: l; Inspector Information Inspection Dater_J Inspector Name: Inspector Company: Commonwealth Tank Inc. inspector CD# Address: 8q S City Wakefield State MA Zip 01880 Phone: 617-628-8260 Qualification: State Approved Third Party Inspector Section Is a license to store flammables/combustibles posted on site(Fortn FP-2)? es ❑No ❑NA Is a current certificate of registration posted on site(Form FP-5)? ITYes ❑No ❑NA Is a current permit to maintain USTs posted on site(Form FP-290 part 3)? ® Yes ❑No Is the current Form FP-290 accurate?Sec. LA &2. A., must match the FP-290 ZYes ❑No Is financial res onsibili verified? Yes ❑No Veri that A,B,&C Operators have been trained. [?Yes CI No Attach most recent Form FP-290 2 Attached Fill out the tank number for each tank using the MassDEP tank number system found on the FP-290. Use a second form for facilities with more than Q tanks, SectionInformation Total Number of Tanks on Site: Information: TANK# TANK# TANK# TANK# 1 Owner Tank#: Tank Serial#: Geographic Location of Tanks-Latitude: �1 °02; `,0(�?5 Geographic Location of Tanks-Longitude Ij+5 ,1St'� 4aak{+6 IS " qj-�y I'sy �S�+ Use degrees, minutes and seconds. Examples: Lat. 42, 36, 12 N Long. 85, 24,17 W Status: 9 In Use 19,111 Use 21n Use 1�1 In Use If out of use, complete 2.B. ❑ Temp Out of Use ❑Tentp Out of Use ❑Tenlp Out of Use ❑Temp Out of Use ❑ Perm Out of Use ❑Perm Out of Use ❑ Penn Out of Use ❑ Perm Out of Use Total Capacity of Tank:(gal) -do IWP 2-61 CICP ,;Z-0 CDC(D �uIIc~,0� Is tank a split(compartment)tank? ❑ Yes No ❑Yes IiNo ❑ Yes o ❑ Yes o Capacity of each compartment. (gal.} Fora 10,000 allankshosv 800012000 I N ' Tank Contents I Product: For split rank slroiv produce tK2 Ri ck 6,k �P- fbe\CAt � 0 ve! t' V'vej ( `� asoline/kerosene)in sauce order as cotrterrt Does tank contain gasoline and/or diesel? 11 asoline ❑gasoline ❑ gasoline El Gasoline 1n parlor whole of lank (comporimented)for any part or V Diesei ❑Diesel Q'Diesel 2,6iesel whole o the ywar. If yes, for road use or for marine fueling? ❑ Road Use ❑ Road Use ❑ Road Use ❑Road Use Leave blank if other ❑ Marina ❑Marina ❑ Marina ❑Marina Used for emergency power generator ❑ Yes No ❑ Yes BNo ❑ Yes ErNo ❑Yes 9-f4o Tank Construction Material } ill Cc N-'CA k Pf-\ecW1 SF A - z S ek Ste.e! s�,e1 Tank Wall Type: Single or Double 9SW ❑ DW 0 SW ❑ DW qSW ❑ DW 9SW ❑DW Piping Type I Pipe Construction Material Ct I"ec1 , �.�tt �: -I SV,,\ t'v`ec� � A ,t \� S,'t i Pipe Wall Type: Single or Double 21SW ❑ DW SW ❑ DW B`SW ❑ DW SW ❑DW ? Multiple Runs Per Tank, Eyes show on map ❑ Yes EKNo ❑ Yes ErNo ❑Yes ❑No ❑Yes ❑No Inspector's Initials Owner/Operator's Initials: Date FP-289 (Rev 9/2009)- Page 2 Date: ] ^(v .Sect1 i.: Inspector Information ]nsj3ection Date: Inspector Name: Luis Diaz Inspector Company: Commonwealth Tank Inc. Inspector ID# 1083 Address: 84 New Saletn Street City Wakefield State MA Zip 01880 Phone: 617-628-8260 Qualification: State Approved Third Party Inspector SectionInformation Is a license to store flammables/combustibles posted on site kForni FP-2)? ®Yes ❑ No ❑NA Is a current certificate of registration posted on site(Form FP-5)? W Yes ❑No ❑NA Is a current permit to maintain USTs posted on site(Form FP-290 part 3)? W Yes ❑No Is the current Form FP-290 accurate?Sec. 1.A &2. A.. must match the FP-290 ©Yes ❑No Is financial responsibility verified? 0 Yes ❑No Verify that A, B,&C Operators have been trained. ® Yes ❑No Attach most recent Forth FP-290 0 Attached Fill out the tank number for each tank using the MassDEP tank number systein found on the FPR290. Use a second form for facilities with more than 4 tanks. SectionInformation Total Plumber of Tanles on Site: General Information: Tartrc# T,�vrc# Tatvtc# Tarvtc# Owner Tank#: Tank Serial#: Geographic Location of Tanks-Latitude: �i"Ggrgt�ta7"1�1 7(�0$`1Io.(5 Geographic Location of Tanks-Longitude !S"�� �1°41!5�1 5t`iLj Use degrees, minutes and seconds. Examples: Lat. 42, 36, 12 N Long, 85, 24,17 ff" Status: In Use R111 Use ❑ In Use ❑ 1pi Use If out of use, complete 2.B, ❑Temp OLA of Use ❑Temp Out of Use ❑Temp Out of Use ❑Temp Out of Use ❑ Pernl out of Use ❑ Perm Out of Use ❑ Perm Out of Use ❑ Perm Out of Use Total Capacity of Tank: (gal.) 901wo 10 t 0+C) Is tank a split(compartment)tank? ❑Yes 119'No ❑ Yes No ❑ Yes No ❑ Yes ❑ No Capacity of each compartment: (gal.) For a 10.000 al truck shoi1,8000/2000 A) '/I A Tank Contents/Product: For split rank show product rrsolimIkerosene)in same order as cowent Does tank contain gasoline and/or diesel? ❑ Gasoline ❑ Gasoline ❑ Gasoline ❑Gasoline In part or whole oftank (compar•trnented)forany parr or [Zbiesel D'Diesel ❑ Diesel ❑ Diesel whole o the year. If yes, for road use or for marine fueling? ❑Road Use ❑Road Use ❑ Road Use ❑ Road Use Leam blank if other ❑ Marina ❑ Marina © Marina ❑ Marina Used for emergency power generator ❑Yes Mlslo ❑Yes 2No ❑ Yes Cl No ❑ Yes ❑No Tank Construction Material 0l•"�4'Wtl AIN,ti,W,`.��{(q t7 U6A S-W— 1"fl t G�cGG (ecf Tank Wall Type: Single or Double LTSW ❑ DW SW ❑DW ❑ SW ❑ DW ❑ SW ❑ DW Piping Pipe Construction Material IJ J} cr t y � US lLY� Pipe Wall Type: Single or Double SW ❑ DW ITSW ❑ DW ❑ SW ❑ DW ❑ SW ❑ DW Multiple Runs Per Tank,ifyesshow on Wrap ❑ Yes No ❑ Yes ITNo ❑ Yes ❑No ❑ Yes ❑No Inspector's Initials Owner/Operator's Initials; Dater —/�5 FP-289 (Rev 9/2009)-Page 2 Date: I 'Select Pr'i�Method. I TANKH TANK# TANKH TANK# `1- If yes,proceed to 1 section: Automatic Tank Gauging(ATG) 3.A. Continuous In-Tank Leak Detect System(CLDS) ❑ ❑ ❑ ❑ 3.0. Interstitial Monitoring(IM) ❑ ❑ ❑ ❑ 3.c. Inventory Control/Statistical Inventory ❑ ❑ ❑ ❑ 3.D. Reconciliation(SIR) Other (EXPLAIN) NA The entire piping system must meet the standard, including split pipes. For piping systems that have been partially replaced,the inspection report must be completed for the least compliant/oldest sections of pipe. Pipe numbers on sketch in 2.C, correspond with pipe/tank number below. Pipe Leak Detection I TANK# TANK# TANKH TANKH If yes,proceed to section: FressurWd piping only Automatic line leak detector(3 gph)&double-wall ❑ ❑ ❑ ❑ pipe with liquid sump sensor or with manual 3.C.AND 3.G. Interstitial Monitoring ALLD(3 gph)&annual line tightness test ❑ ❑ ❑ ❑ 3.E.AND3.G. ALLD that can perform 3 gph continuous plus ❑ ❑ ❑ ❑ 0.2 h/month(electronic) 3.G. Other (EXPLAIN) Suction Piping.only. Interstitial monitoring ❑ ❑ ❑ ❑ 3.C. Periodic Tightness Testing(non-European) ❑ ❑ ❑ ❑ 3.F_ European Suction 3.F. Other (EXPLAIN) TANK# i TANKH TANKS' 3 TANK# If yes,proceed to t section: Galvanic Cathodic Protection(GC)Tank and/or g•A• Pi in Impressed Current (IC)Tank and/or Piping g,n, Non-Metal Piping(NM)Tank AND Piping ❑ ❑ ❑ ❑ 5.c. Whole system must be non-metal to complete this section. Other (EXPLAIN) NA Fill out this section for any tank that is "temporarily closed"(contains product but is out of service)or is"taken out of service" (empty and out of service).A complete inspection of these tanks is required. Note: This section does not apply to a tank that is currently in use or permanently closed within 527 CMR 9. i i I 1 TANK# TANK# TANK# TANK# or Taken Out of Service 005-- Tank contains less than one inch of product ❑ Yes ❑No ❑ Yes ❑No ❑Yes ❑No ❑Yes ❑No Fill pipe locked or secured to prevent access [] Yes []No ❑Yes ❑No ❑ Yes ❑No ❑Yes ❑No Date tank was"temporarilyclosed"(Mond7lYear) Verify max time for Temp Out of Service: ❑Yes ❑No ❑ Yes ❑No ❑Yes ❑No ❑Yes ❑No Single Wall Tanks-6 months Double Wall Tanks-24 months Fire Department Permit Posted ❑Yes ❑No ❑Yes ❑No ❑ Yes ❑No ❑Yes ❑No Inspector's Initials Owner/Operator's Initials: Date ;�— f/d FP-289 (Rev 9/2009)-Page 3 Date: - `"/ Select Primary Method. Tank Leak Detection 1 TANIC# TANK# r TANK# TANKS If yes,proceed to (� section: Automatic Tank Gauging(ATG) 7 ❑ ❑ 3.A. Continuous In-Tank Leak Detect System(CLDS) ❑ ❑ ❑ ❑ 3.B. Interstitial Monitoring(IM) ❑ ❑ ❑ ❑ 3.c. Inventory Control/Statistical Inventory ❑ ❑ ❑ ❑ 3.0. Reconciliation (SIR) Other (EXPLAIN) NA The entire piping system must meet the standard, including split pipes. For piping systems that have been partially replaced,the inspection report must be completed for the least cornpliandoldest sections of pipe. Pipe numbers on sketch in Z.C. correspond with pipe/tank number below. jPipe Leak Detection I TANK# TANK# TAN TANK# If yes,proceed to section: Pressurized piping only U El Automatic line leak detector(3 gph)&double-wall ❑ pipe with liquid sump sensor or with manual 3.c.AND 3.G. Interstitial Monitoring ALLD(3 gph)&annual line tightness test ❑ ❑ ❑ ❑ 3.E. AND 3.c. ALLD that can perform 3 gph continuous plus ❑ ❑ ❑ ❑ 3.c. 0.2 hi month(electronic) Other (EXPLAIN) Suction piping only Interstitial monitoring ❑ ❑ ❑ ❑ 3.c. Periodic Tightness Testing(non-European) ❑ ❑ ❑ 3.E. European Suction 0 ❑ Other (EXPLAIN) �Corrosion Prevention I TANK# C TANK# TANK# TANK# If yes,1)rocced to > section: Galvanic Cathodic Protection(GC)Tank and/or ❑ ❑ S.A. Piping Impressed Current (IC)Tank and/or Piping ❑ ❑ S.B. Non-Metal Piping(NM)Tank AND Piping ❑ ❑ ❑ ❑ 5,C, Whole system must be non-metal to complete this section. Other (ExPLA1N) NA Fill out this section for any tank that is"temporarily closed" (contains product but is out of service)or is "taken out of service" (empty and out of service).A complete inspection of these tanks is required. Note: This section does not apply to a tank that is currently in use or permanently closed Ivithin 527 CMR 9. Sectioni.: Tank Temporarily ClosedTANK# TANK# TANK# TANK# or Taken Out of Service Tank contains less than one inch of product ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑ No Fill pipe locked or secured to prevent access ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No Date tank was Aemporarilyclosed'(dlw:rh/Yea,J Verify max time for Ternp Out of Service: ❑ Yes ❑No ❑ Yes ❑ No ❑ Yes ❑No ❑ Yes ❑ No Single Wall Tanks-b months Double Wall Tanks-24 months Fire Department Permit Posted ❑ Yes ❑No ❑Yes ❑No ❑ Yes ❑No ❑ Yes ❑No Inspector's Initials Owner/Operator's Initials: Date - FP-289 (Rev 9/2009)-Page 3 Date: -) 1176nk is permanently closed, is FP-290R on file? I ❑Yes ❑No ❑Yes ❑No ❑ Yes ❑No ❑Yes ❑No i basic layout of FbrSplit/Compartmented tanks label sections separately(for example I& IB). LEGEND KEY ❑ T North arrow ❑ (A)Alarms ❑ (All)Impressed current anodes 0 (ATG)Automatic tank gauge consoles ❑ (D)Dispensers 0 (DW)Private water well ❑ (P)Product piping ❑ (PS)Piping sumps ❑ (R)Reference cell locations for CP ❑ (RCT)Rectifiers * (S)Structure contact points for CP ❑ (T)Tank,include tank#(identify all compartments) O O EP) O 201000 colon 0 20,000 01allon 10,000 0�10n O 20,000 II ElO � 11 O a <=:) a O 20,000 Ion a rim (P) (D) a O o 20,000 allcn OVertical Anode O Horizontal Anode (D) ❑ kmction PM O O O P t Merrimack Valley Oil pad: Ni fo Eomeank Inn, wed : W I lrann Pq 544 OT/V/10 Jeofe M H.r Wwn ahwt Moto w omw Inspector's Initials Owner/Operator's Initials: Date / FP-289 (Rev 9/2009)-Page 4 Date: �) -------------- (Tank Only) 1n 3.A.: Automatic Tank Gauging TANK# � TANK# TANK# � TANK# Console Make and Model Vee6et lZOOA \tee'�Qr ` MT \f eeA—et Q(Xv TLS-'25-C) 3s6 "RS 3S70 2 Probe Type Model- Fill out for each tank \leedet Qna Ve,4ey Zoa v e. Jec (W er m l\4 c VOCC ft3lNe,4tc tv1J�0 )A MkL M q1114 CWr 3 Frequency: How often does ATG perform test? ❑J�aiiy ❑ Daily ❑ Daily ❑ Daily Continual Statistical Leak Detection(Daily) w Monthly tA-54onthly onthly U-Monthly Six Hour In-Tank Test(It90nthl) 4 Device is calibrated,operated,and Yes ❑No Cl'Vrs ❑No es ❑No 9--Ves ❑No maintained per manufacturer's instructions Gaut ale:f ec ue�r ofselvice checks,etc.). 5 System setup reviewed. Proper settings were Yes ❑No es ❑No B`Yes ❑No es ❑ No confirmed and are correct. Verification that all probes are functioning. G Monitoring panel or control box is present LdYes ❑No ffYes ❑No DYes ❑No es ❑No and working. 7 Tank is filled to proper capacity and test run 9 Yes ❑ No Yes ❑No Yes ❑No es ❑No for proper duration of time during the last 2 ❑New Tank ❑New Tank ❑New Tank ❑New Tank months, in accordance with manufacturer's instructions. 8 Owner's manual for console and probes is Yes ❑No ITYes ❑No ITYes ❑No D-Yes ❑No available at the site. 9 Verification that console and probe are third- Yes ON o es ❑No es ❑No ©-Ves ❑No party approved. 10 ATG meets minimum performance standards, Ef Yes ❑No Yes ❑No Q- 'es ❑No 19-Yes ❑No with the probability of detection set at 0.95% and the probability of false alarm set at 0.05% 1 t Existing release detection results show no IYVes ❑No 9Ws ❑No es ❑No I9-Yes ❑ No evidence of a release. 12 ATG is checking the portion of the tank that 0 Yes ❑No Yes ❑No Yes ❑No es ❑ No routinely contains product, in accordance with manufacturer's instructions. 13 Monthly release detection records are available Yes ❑No es ❑No Eames ❑No es ❑ No for last 12 months. ATG records must show El New Tank ❑New Tank ❑New Tank ❑ New Tank that 8 of the past 12 months have a passing test, without 2 consecutive months of inconclusive results. 14 Number of Passing Months 1 Pass El Pass ❑ Fail Pass El Fail Pass ❑ Fail Blocks or New Tank- !f the ans)ver to arty question is No,please explain below. List any problems noted during inspection.Note corrections on addenthou. DEFICIENCIES: � � W /I9 92c' A Ai z�. P 6 X2 A2 c/ M Fum-w RlImpmMENDATIONS. c l _ Inspector's Initials D Owner/Operator's Initials: Date 'tea FP-289 (Rev 9/2009)-Page 5 Date: + Automatic TANK# � TANK# L7 TANKi� TAfVK{# I Console Make and Model qee�u m; 2 Probe Type Model-Fill out for each tank fee w( PW lee-A-e� vL P 3 Frequency: How often does ATG perform test? ❑ Daily ❑ Daily ❑ Daily n Daily Continual Statistical Leak Detection(Daily) I2Monthly B Monthly ' Monthly k4onthly Six Notn•/n-Tank Test(Monthly) Yes 4 Device is calibrated,operated,and ❑No Yes El No ❑ Yes ❑No El Yes El No maintained per manufacturer's instructions (fzrnr le.• • en o service checks,etc). 5 System setup reviewed. Proper settings were ffy1cs ❑Na es ❑No ❑Yes ❑No ❑Yes ❑No confirmed and are correct.Verification that all probes are functioning. 6 Monitoring panel or control box is present Yes l]No WY-es ❑No 'cs ❑No ❑ Yes ❑No and working. 7 Tank is filled to proper capacity and test run Yes ❑No es ❑No ❑ Yes ❑No ❑ Yes ❑No for proper duration of time during the last 2 ❑New Tank ❑New Tank ❑New Tank ❑New Tank months, in accordance with manufacturer's instructions. 8 Owner's manual for console and probes is DYes ❑Na es ❑No ❑Yes ❑No ❑ Yes []No available at the site. 9 Verification that console and probe are third- ❑Yes ❑No ❑Yes ❑No ❑ Yes ❑No ❑ Yes ❑No paq a2proved. 10 ATG meets minimum performance standards, Ef Yes ❑No Yes ❑No ❑ Yes ❑No ❑ Yes ❑No with the probability of detection set at 0.95% and the probability of false alarm set at 0.05% 1 I Existing release detection results show no gVes ❑No Yes ❑No es ❑No 'es ❑No evidence of a release. 12 ATG is checking the portion of the tank that Yes ❑No Yes ❑No ❑Yes ❑No ❑ Yes ❑No routinely contains product, in accordance with manufacturer's instructions. 13 Monthly release detection records are available ffYes ❑No BYcs ❑No ❑ Yes ❑No ❑ Yes ❑No for last 12 months. ATG records must show ❑New Tank ❑New Tank ❑New Tank ❑New Tank that 8 of the past 12 months have a passing test, without 2 consecutive months of inconclusive results. 14 Number of Passing Months SectionPass ❑Fail Pass ❑ Fail ❑ Pass ❑Fail ❑Pass ❑Fail Blocksor 1f the answer to any question is No,please explain belom list any problems rioted daring inspection. Note corrections on addendum. DEFICIENCIES: FURTHER RECOMMENDATIONS: Inspector's Initials Owner/Operator's Initials: Date FP-289 (Rev 9/2009)-Page 5 Date: 10 Section : Continuous Detection 1 TANK# TANK# TANK# TANK# 1 Console Make and Model 2 Probe Model. Fill in for each tank. 3 Device is calibrated, operated,and ❑Yes ❑No ❑ Yes ❑No ❑ Yes []No ❑Yes ❑No maintained per manufacturer's instructions (example:frequency of service checks,etc.)including limitations listed on evaluation summary. 4 System setup reviewed. ❑ Yes ❑No ❑ Yes ❑No ❑Yes ❑No ❑Yes ❑No Proper settings were confinned and are correct. Verification that all probes are functioning. 5 Monitoring panel or control box is present ❑ Yes ❑No ❑ Yes ❑No ❑Yes ❑No ❑ Yes ❑No and working. 6 Owner's manual for console and probes is ❑ Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No available at site. 7 Verify that console and probe are third-party [] Yes ❑No ❑Yes ❑No ❑ Yes ❑No ❑Yes ❑No approved. 8 CLDS meets minimum performance ❑ Yes ❑No ❑ Yes ❑No ❑Yes ❑No ❑Yes ❑No standards,with the probability of detection set at 0.95%and the probability of false alarm set at 0.05% 9 Existing release detection results show no ❑Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑Yes []No evidence of a release. 10 CLDS is checking the portion of the tank ❑ Yes ❑No ❑ Yes ❑No ❑Yes ❑No ❑Yes ❑No that routinely contains product, in accordance with manufacturer's instructions. I I Monthly release detection records are ❑ Yes ❑No ❑ Yes ❑No ❑Yes ❑No ❑ Yes ❑No available for last 12 months. CLDS records ❑New Tank ❑New Tank ❑New Tank ❑New Tank must show that 8 of the past 12 months have a passing test,without two consecutive months of inconclusive results. 12 Number of Passing Months i ❑ Pass ❑ Fail ❑ Pass ❑Fail El Pass El Fail ❑Pass ❑Fail ii i ft If the answer to any question is No,please explain below.List any problems noted during inspection.Note corrections on addendum. DEmCIENCWS: FURTHER REC©M1VIl;NDATIONS: Inspector`s Initials 40 Owner/Operator's Initials: Date FP-289 (Rev 9/2009)-Page 6 Date: �� TANK# TANK# TANK# TANK# 7aintained onsole Make and Model robe Model. Fill in for each tank. evice is calibrated,operated, and ❑ Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑ Yes ❑ No per manufacturer's instructions (example:fi-equencyofservice checks,etc.)including limitations listed on evaluation summary. 4 System setup reviewed. ❑ Yes ❑No ❑Yes ❑No ❑ Yes ❑ No ❑ Yes ❑ No Proper settings were confirmed and are correct. Verification that all probes are functioning. 5 Monitoring panel or control box is present ❑ Yes ❑No ❑Yes ❑No ❑ Yes ❑No ❑ Yes ❑No and working. 6 Owner's manual for console and probes is ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No available at site. 7 Verify that console and probe are third-party ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No approved. 8 CLDS meets minimum performance ❑ Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑ Yes ❑ No standards, with the probability of detection set at 0.95%and the probability of false alarm set at 0.05% 9 Existing release detection results show no ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No evidence of a release. 10 CLDS is checking the portion ofthe tank ❑ Yes ❑ No ❑ Yes ❑No ❑ Yes ❑No [] Yes ❑ No that routinely contains product, in accordance with manufacturer's instructions. I I Monthly release detection records are ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑ No available for last 12 months. CLDS records ❑ New Tank ❑New Tank ❑ New Tank ❑ New Tank must show that 8 of the past 12 months have a passing test,without two consecutive months of inconclusive results. i 2 Number of Passing Months ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail If the answer to any question is No,please explain below.List any problems noted during inspection.Note corrections on addendirrn. DEFICIENCIES: FURTHER RECOMMENDATIONS: Inspector's Initials 49 Owner/Operator's Initials: _ Date �r 7 -49 FP-289 (Rev 9/2009)-Page 6 Date: -1L) 1 I e JIM, Flamm. 1 I TANK# TANK# `I`ANK# TANK# I Interstitial space is filled with ❑ Brine❑ Dry ❑ Brine ❑Dry ❑Brine❑ Dry ❑Brine❑ Dry liquid Brine or gas(Dry). 2 Type of interstitial sensor. ❑Liquid ❑ Liquid ❑ Liquid ❑ Liquid (i.e.,Liquid,Discriminating,Pressure) ❑ Discriminating ❑ Discriminating ❑ Discriminating ❑Discriminating ❑ Pressure ❑Pressure ❑ Pressure ❑Pressure 3 Console make and nrade: q Sensor make and model 5 Monitoring console is operational. ❑Yes ❑No ❑Yes ❑No ❑ Yes ❑No ❑Yes ❑No Interstitial sensor visually inspected, ❑Yes ❑No ❑Yes ❑No ❑ Yes ❑No ❑Yes ❑No functionally tested,and confirmed operational. 7 Sensor monitors the interstitial space in the ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑Yes ❑No appropriate osition. 8 Device is calibrated,operated,and ❑Yes ❑No ❑Yes []No ❑ Yes ❑No ❑Yes ❑No maintained per manufacturer's instructions, example.- ren o savice checkg eta 9 Tanks Sump is clean and free of debris and ❑Yes ❑No ❑Yes ❑No ❑ Yes ❑No ❑Yes ❑No water. 10 Monthly release detection records are ❑Yes ❑No ❑Yes ❑No ❑ Yes ❑No ❑Yes ❑No available for last 12 months. Interstitial ❑New Tank ❑New Tank ❑New Tank ❑New Tank monitoring must show that 8 of the past 12 months have passed with no more than two inconclusive records, 1 I Number of passing months: [] Pass El Fail [] Pass ❑ Fail [I Pass El Fail El Pass ❑Fail i 1 1 If the answer to any question is No,please explain below. List any problems noted during inspection.Note cot rections on addendant. DEFICIENCIES: FURTHER RECOMMENDATIONS: Inspector's Initials Owner/Operator's Initials: Date %3 FP-289 (Rev 9/2009)-Page 7 Date: w — 1cJ 777 TANK## TANK# TANK# TANKU ce is filled with ❑ Brine Cl Dry ❑ Brine ❑ Dry ❑ Brine❑ Dry ❑ Brine ❑ Dry or as Drtitial sensor. ❑ Liquid ❑ Liquid ❑ Liquid ❑ Liquid Discrimivating,Pressure) ❑ Discriminating ❑ Discriminating ❑ Disciminating ❑ Discrilninating ❑ Pressure ❑ Pressure ❑ Pressure ❑ Pressure It make and mode: 4 Sensor make and model 5 Monitoring console is operational. ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑ No ❑ Yes ❑ No 6 Interstitial sensor visually inspected, ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑ No functionally tested, and confirmed operational. 7 Sensor monitors the interstitial space in the ❑ Yes ❑No ❑ Yes ❑ No ❑ Yes ❑No ❑ Yes ❑No appro2riate position, g Device is calibrated,operated,and ❑ Yes ❑No ❑ Yes ❑ No ❑ Yes ❑No ❑ Yes ❑ No maintained per manufacturer's instructions. (exaiiiple,* -egiiejicyofseiiicechecks,etc 9 Tanks Sump is clean and free of debris and ❑Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No water. 10 Monthly release detection records are ❑ Yes ❑No ❑ Yes ❑ No ❑ Yes ❑No ❑ Yes ❑ No available for last 12 months. Interstitial ❑New Tank ❑New Tank ❑ New Tank ❑New Tank monitoring must show that 8 of the past 12 months have passed with no more than two inconclusive records. 11 Number of passing months: Section ❑ Pass ❑ Fail ❑ Pass ❑ bail ❑ Pass ❑ Fail ❑ Pass ❑ Fail Blocks1 are Yes or New Tank If the anslver to anV question is No,please explain below. List my problems noted during inspection.Note corrections on addendam. DEFICIENCIES: FURTHER RECOMMENDATIONS: Inspector's Initials 2d Owner/Operator's initials: Date FP-289 (Rev 9/2009)- Page 7 Date: 1 I F Only TAiVI{# TANK# TAtvK# TANK# 1 Method Name: 2 Readings are recorded daily when operating. ❑ Yes ❑No ❑ Yes ❑No ❑Yes ❑No ❑ Yes ❑No 3 Inventory records are reconciled monthly. ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No 4 Appropriate calibration chart is used for ❑Yes ❑No ❑Yes ❑No Cl Yes ❑No ❑ Yes ❑No calculating volume to nearest 1/8 inch. 5 Stick readings are logged before each ❑Yes ❑No ❑ Yes ❑No ❑Yes ❑No ❑Yes ❑No delivery. 6 Stick readings are logged after each ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No delivery. 7 Gauge stick is marked to determine product ❑Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No level to the nearest 1/8 inch. 8 Gauge stick can measure to full height of ❑ Yes ❑No ❑ Yes ❑No ❑Yes ❑No ❑ Yes ❑No tank. 9 Monthly water readings checked to the nearest ❑Yes ❑No ❑Yes ❑No ❑ Yes ❑No ❑ Yes ❑No I/8 inch and used to calculate inventory balances.If water intrusion is noted, list in "Deficiencies." 10 Fill dro tubc is installed and functional. ❑ Yes ❑No ❑ Yes ❑No ❑Yes ❑No ❑ Yes ❑No 1 I Each dispenser is metered and recorded ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No within state or local standards for meter calibration. 12 Date meter calibrated: 13 Total monthly overages for shortages) are ❑Yes ❑No ❑Yes ❑No ❑ Yes ❑No ❑ Yes ❑No less than 130 gallons plus one percent of tank's flow-through(sales)volume for the last 12 months. 14 SIR results received by owner from vendor ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No within 30 days of submittal of data. 15 SIR results indicate sufficient amount of data ❑Yes ❑No ❑Yes ❑No ❑ Yes ❑No ❑ Yes ❑No was used to perform leak check. 16 Existing release detection results indicate ❑Yes ❑No ❑Yes []No ❑Yes ❑No ❑Yes ❑No o eration without evidence of a release. 17 Monthly release detection records are ❑ Yes ❑No ❑Yes ❑No ❑ Yes ❑No ❑ Yes ❑No available for the last 12 months. Monitoring ❑New Tank ❑New Tank ❑New Tank ❑New Tank must show that eight of the past 12 months have a passing record,with no more than two consecutive months of inconclusive results. I No,report Leak to MrrssDEP. 18 Number of passing months: SectionI ❑ Pass ❑Fail ❑Pass ❑Fail ❑ Pass ❑ Fail ❑ Pass ❑Fail If the answer to any question is No,please explain below.List any problems noted dtiring inspection.Note corrections on addendum. DEFICIENCIES' FMTRER RECOMAIENDATIONS: Inspector's Initials Owner/Operator's Initials: Date FP-289 (Rev 9/2009)-Page 8 Date: l� 1 TANK# TANK# TANK# TANK4 1 Method Name: 2 Readings are recorded dailywhen operating. ❑ Yes ❑No ❑Yes ❑No ❑ Yes ❑No ❑ Yes ❑No 3 Inventory records are reconciled monthly. ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No 4 Appropriate calibration chart is used for ❑ Yes ❑ No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No calculating volume to nearest 1/8 inch. 5 j Stick readings are logged before each ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No delivery. G Stick readings are logged after each ❑ Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑ Yes ❑No delivery. 7 Gauge stick is marked to determine product ❑ Yes ❑ No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No level to the nearest 1/8 inch. 8 Gauge stick can measure to full height of ❑Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No tank. 9 Monthly water readings checked to the nearest ❑Yes ❑No Cl Yes ❑No ❑Yes ❑No ❑Yes ❑No 1/8 inch and used to calculate inventory balances. If water intrusion is noted, list in "Deficiencies." 10 Fill drop tube is installed and functional. ❑Yes ❑ No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No 1 I Each dispenser is metered and recorded ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes [-]No within state or local standards for meter calibration. 12 Date meter calibrated: 13 Total monthly overages (or shortages] are ❑ Yes ❑ No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑ No less than 130 gallons plus one percent of tank's flow-through(sales)volume for the last 12 months. 14 SIR results received by owner from vendor ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑ No ❑ Yes ❑ No within 30 days of submittal of data. 15 SIR results indicate sufficient amount of data ❑Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No was used to perform leak check. 16 Existing release detection results indicate ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑ No ❑ Yes ❑ No operation without evidence of a release. 17 Monthly release detection records are ❑Yes ❑ No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑ No available for the last 12 months. Monitoring ❑New Tank ❑New Tank ❑ New Tank ❑ New Tank must show that eight of the past 12 months have a passing record,with no more than two consecutive months of inconclusive results. if No,report Leak to MassDEA 18 Number of passing months: ❑Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail r 'If the ansnver to any question is No,please explain below.List any problems noted during inspection,Note corrections on addenthrrn. DEFICIENCw,s• FURTHER RECOMMENDATIONS: i l E g 1 Inspector's Initia� Owner/Operator's Initials: 63 Date FP-289 (Rev 9/2009)-Page 8 Date: fV I. 1 E PIPEH PIPEiH PIPEN PIPE# r2 — Method ethod is a 0.1 gph tightness test, ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑Yes ❑No Name: 3 Tightness test performed by(Person or Company Name): a Last tightness test results available and ❑Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑Yes ❑No passed. Shows no evidence of a potential release. 5 Tightness testing is conducted withinI ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑Yes ❑No specified time frames for method;annually for pressurized piping; every 3 years for non- exem t suction i in . Section 3.E Passes if ❑Pass ❑Fail ❑Pass ❑ Fail ❑ Pass ❑ Fail ❑Pass ❑Fail Blocks If the answer to any question is No,please explain below.List any problems noted during inspection.Note corrections on addendum. DEFICIENCIES: FURTI l ER RECOMIVIEmATIONs: [111 IRA1 1 k _ { PIPEH PIPE 1 r} PIPE# � PIPE# �f 1020nly he piping slope is back to the tank and Yes ❑Na Yes El No Imes ❑No es ❑No operates under atmospheric pressure or less. one check valve is used. l-Yes ❑No Yes ❑No es ❑No R'fes ❑No 3 The check valve is directly under the ❑•Yes ❑No Yes ❑No es ❑No es ❑No dispensing pump. 1ErPass ❑Fail Pass ❑Fail [a-6ss ❑ Fail Q-Pass ❑ Fail it OH Ir"11!01I 110111"111I lim If the answer to any question is No,please explain below.List any problems noted during inspection.Note corrections on addendu►rr. DEIi ICIENCIES: i FURTHER RECOMMENDATIONS: B i' t c Inspector's Initials Owner/Operator's Initials: Date — FP-289 (Rev 9/2009)-Page 9 Date: -!d Section Periodic II Tightness Testing Non-European 1 ' P1rE# PIPIT# PIPE# PIPE# ,1 Test method is a 0.1 gpli tightness test. ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑ No 2 Method Name: 3 Tightness test performed by(Pelson or Company Name): d Last tightness test results available and ❑ Yes ❑ No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑ No passed. Shows no evidence of a potential release. S Tightness testing is conducted within ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑ No specified time frames for method;annually for pressurized piping; every 3 years for non- exem t suction Section ❑ Pass ❑ Fail ❑ Pass ❑Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail Blocks t f the ans3per to m:.I,question is No,please explain belo►p. List may proble►rrs noted during lrrspeetio►►.Note corrections on addenrhrrrr. DEFICIENCIES: FURTHER RECOMMENDATIONS: IL PIPE# PIPE PIPE# PIPE# •� � e b 1 The piping slope is back to the tank and es ❑No es ❑No ❑ Yes ❑No ❑ Yes ❑ No operates under atmospheric pressure or less. 2 Only one check valve is used. es El No Yes ❑No ❑ Yes ❑No ❑ Yes ❑ No 3 The check valve is directly under the es ❑Na FD4es ❑No ❑ Yes ❑No ❑ Yes ❑ No dispensing punt . Pass 0 Fail Pass ❑Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail If the rnrsaper to any question is No,please explain belo►p. List any problems noted during inspection.Note corrections on addendron. DEFICIENCIES: FURTHER RECOMMENDATIONS: u inspector's htiti Owner/Operator's initials: Date �� FP-289 (Rev 9/2009)-Page 9 Date: " ! I ' ' 1Detectors Piping functioning of ALLDTANKi� TANK#i TANK#i TANICii 1 Mechanical or Electronic ❑Mechanical ❑Mechanical FJ Mechanical ❑ Mechanical ❑ Electronic ❑ Electronic ❑Electronic ❑ Electronic 2 Make and Model 3 El Shut-Off ❑Shut-Off ❑ Shut-Off ❑ Shut-Off Automatic Shut-Off Device( ❑ Restrictor ❑Restrictor El Restrictor El Restrictor Restrictor(R}Audible or Visible ble Alarm(A) ❑Alarm ❑Alarm ElAlarm ElAlarm 4 ALLD device is performing and ❑ Yes ❑No ❑Yes ❑No ❑ Yes ❑No ❑Yes ❑No operational at 3.0 g h @ 10 psi 5 ALLD device is calibrated,operated,and ❑Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No maintained per manufacturer's instructions (example:fi-equency of service checks,etc.) b ALLD has operated without evidence of a [] Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑Yes ❑No release. 7 The entire piping system is covered by the ❑Yes ❑No ❑ Yes ❑No ❑Yes ❑No ❑Yes ❑No ALLD. 8 ALLD is third-party certified and passed ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No an annual functional test each year prior to this inspection. All ALLDs must pass an annual functional(operations)test, in accordance with manufacturer's specifications,to assure it is ro erl installed,not tampered or bypassed,etc. I [] Pass ❑Fail ❑Pass ❑ Fail ❑ Pass ❑Fail ❑Pass ❑Fail iI If the ans►ver to any question is No,please explain below. List any problems noted during inspection.Note corrections on addendu►n. DEFICIENCIES: FURTHER REC©MMENDATIONS: Inspector's Initials Owner/Operator's Initials: Date — IT4 O FP-289 (Rev 9/2009)-Page 10 Date: 77 Automatict (ALLD) (Pressurized Piping Only) Check type i functioning of ALLDTANK# TALK# TANK# TANK# I Mechanical or Electronic ❑ Mechanical ❑ Mechanical ❑ Mechanical ❑ Mechanical ❑ Electronic ❑ Electronic ❑ Electronic ❑ Electronic 2 Make and Model Automatic Shut-Off Device(S-O) ❑ Shut-Off El Shut-Off ❑ Shut-Off ❑ Shut-Off Restrictor(R}Audible or Visible Alarm ❑ Restrictor El Restrictor ❑ Restrictor El Restrictor ❑ Alarm ❑ Alarm ❑Alarm ❑ Alarm (A) 4 ALLD device is performing and ❑Yes ❑No ❑ Yes ❑No ❑Yes ❑No ❑ Yes ❑No op erational at 3.0 gph @ 10 psi 5 ALLD device is calibrated, operated, and ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No maintained per manufacturer's instructions (exam le:fileguency ofservice checks,etc.) g ALLD has operated without evidence of a []Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑ No release. 7 The entire piping system is covered by the ❑Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ALLD. 8 ALLD is third-party certified and passed ❑ Yes ❑No ❑Yes []No ❑Yes ❑No ❑ Yes ❑No an annual functional test each year prior to this inspection. All ALLDs must pass an annual functional(operations)test, in accordance with manufacturer's specifications,to assure it is roper) installed, not tam eyed or by assed,etc. Section 3.G. Passes if ❑ Pass ❑ Fail ❑Pass ❑Fail ❑ Pass ❑ Fail [] Pass ❑ Fail Blocks If the answer to air r question is No,please explain below. List an.p pr•oblenrs noted during inspection. Note corrections on addendum. DEFICIENCIES: FURTHER RECOMMENDATIONS: i I i i d H 6 pdyB Inspector's Initials „__..,. Owner/Operator's Initials: Date _ '� ' -/U FP-289 (Rev 9/2009)-Page 10 Date: a .: . Spill Prevention TANK# ( TANK# 'rpll„ TANK# TAN # �-I 1 Equipped with spill bucket minimum 3 gal. trYes ❑No Yes ❑No Yes ❑No es ❑No capacity.2 Bucket is capable of returning product to the tank. es ❑No Yes El No es El No Yes ❑Na 3 Bucket is clean and free of debris and water. Rr es ❑No Yes ❑No Yes ❑No es ❑No q Bucket and cover is without cracks or holes IJVes ❑No ffVes ❑No Yes ❑No ffYes ❑No observed. 5 Fill pipe is without abnormalities observed(bent Yes ❑No ffYes ❑No ErYes ❑No Yes ❑No drop tubes,cracks or holes)especially at connection to tank and spill device. r WIN 17M a 11 i Rl ma U,,Pass ❑ Fail Pass ❑Fail ass ❑ Fail Gass ❑ Fail If the answer to any question is No,please exptaln below. List any problems noted during inspection.Note corrections an addendum. DEFICIENCIES: FURTHER RECOWAENDATIONS: Section 4.B.: Overfill Prevention TANK# t TANK# � TANK# � TANK# I Overfill device present(select rinra Automatic Shut-off float valve(AS)Ball Float AS El BFV AS El BFV AS ❑BFV AS El BFV Valve(BFV)Hi h Level Alarm(HLA) ❑HLA ❑ LA ❑HLA ❑ HLA 2 Indicate delivery method(gravity or metered flow) Gravity R1 Gravity Gravity n Gravity ❑Metered ❑ etered ❑ etered ❑ etered FInspector verifies installation described below: Yes ❑No Yes ❑No Yes ❑NoRequired.the installation of A.)a device which shall automatically shut off flow into the tank when the tank is no more than 95%full or B.)a device that shall alert the individual delivering the product when the tank is no more than 90%full by restricting the flow into the tank or triggering a hi h level larm. Owner/operator ensures releases due to spilling or Ef Yes ❑No 9Yes ❑No Yes ❑No ETYes ❑No overfilling do not occur. For example,product is rrreasured prior to each delivery to ensure enough room in tank orproduct;all fuel deliveries are inonitored. 5 Visually observed overfill device housing; Yes El No Yes El No Yes El No Yes El No documentation of install provided;OR certification from service provider attesting to overfill device operability rovided. 6 AS: Visual observation indicates the drop tube is es ❑No ErYes ❑No Yes ❑No Yes ❑No unobstructed(anything that would render the shut- off device ineffective). 7 BFV:Valve and/or vent restrictor material is ❑Yes ❑Na ffYes ❑No Yes DNo_i ErYes ❑No compatible with UST system configuration,product, delivery,and use. 8 HLA: Alarm is tested and is functioning properly at ❑ Yes ❑No ff Yes ❑No 15 Yes ❑No Yes ❑No 90%,and is audible or visible to the driver at the point of transfer. Section 4.A. Passes if Pass ❑ Fail ff Pass ❑ Fail 9 Pass ❑Fail Pass ❑Fail Blocks ' are Yes If the answer to any question is No,please explain below.List any problems noted during inspection.Note corrections on addendum. D>JFICIENCIEs: I FMTHER RECOMMENDATIONS: i i i I I Inspector's Initials Owner/Operator's Initials: Date FP-289 (Rev 9/2009)-Page l I Date: " Cv p i 1 1 TANK# � TANI{# l'o TANK# TANK# 1 Equipped with spill bucket minimum 3 gal. M Yes ❑No Yes ❑No ❑ Yes ❑No ❑ Yes ❑ No capacity. 2 Bucket is capable of returning product.to the tank. Yes ❑No Yes ❑No ❑ Yes ❑ No ❑ Yes ❑ No 3 Bucket is clean and free of debris and water. es ❑No Yes ❑No ❑Yes ❑No ❑ Yes ❑No 9 Bucket and cover is without cracks or holes ff Yes ❑No ffl Yes ❑No ❑ Yes ❑No ❑ Yes ❑No observed. 5 Fill pipe is without abnormalities observed(bent Yes ❑ Na Yes ❑No ❑Yes ❑ No ❑ Yes ❑No drop tubes,cracks or holes)especially at connection to tank ands ill device. Section 4.A. Passes if Blocks Pass ❑ Fail Pass ❑ Fail I ❑ Pass ❑ Fail ❑ Pass ❑ Fail If(lie ans►ver•to airy question is No,please explain below.List any problems rioter/daring inspection.Note corrections on addentlrun. DEFICIENCIES: FuRTH ER RECOMMENDATIONS: Section ' i Overfill Prevention TANK# 5 TANK# {� TANK# TANK# 1 Overfill device resent select primary): Automatic Shut-off float valve(AS)Ball Float AS ❑ BFV AS ❑BFV ❑AS ❑ BFV [ -]AS ❑ BFV Valve BFV Hi h Level Alarm(HLA) ❑ HLA ❑ LA ❑ HLA HLA 2 Indicate delivery method(gravity or metered flow) Gravity El Gravity ❑ Gravity ❑ Gravity ❑ etered ❑ etered ❑ Metered ❑ Metered 3 Inspector verifies installation described below: ff Yes ❑No Ff Yes ❑No ❑ Yes ❑No ❑ Yes ❑No Required: the installation of A.)a device which shall automatically shut off flow into the tank when the tank is no more than 95% full or B.)a device that shall alert the individual delivering the product when the tank is no more than 90%full by restricting the flow into the tank or triggering a high level al rm. 4 Owner/operator ensures releases due to spilling or es ❑No Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No overfilling do not occur. For example,product is neasured prior to each deliver),to ensure enough room in tank for product; all iiel deliveries are rnonibred. 5 Visually observed overfill device housing; ❑ Yes ❑No EI Yes ❑ No ❑ Yes ❑No ❑ Yes ❑No documentation of install provided;OR certification from set-vice provider attesting to overfill device operability rovided. 6 AS: Visual observation indicates the drop tube is es ❑No M Yes ❑No ❑ Yes ❑No ❑ Yes ❑No unobstructed(anything that would render the shut- off device ineffective). 7 BFV: Valve and/or vent restrictor material is ❑ Yes ❑No ❑ Yes ❑ No ❑ Yes ❑No ❑ Yes ❑ No compatible with UST system configuration,product, delivery,and use. 8 HLA: Alarm is tested and is functioning properly at ❑Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑ No 90%, and is audible or visible to the driver at the point of transfer. Sectionass ❑ Fail Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail Blocks1 are Yes If lire answer to racy question is No,please explain below. List any problems noted during inspection.Note corrections on addendum. DEFICIENCIES: FURTHER RECOMMENDATIONS. i Inspector's Initials Owner/Operator's Initials: _ Date FP-289 (Rev 9/2009)- Page 11 Date: ,10 i r Select-Pritnary Alethod in Section 5A. S.or C. on, t t ` 90 ' • • • ' TH NKii TANK# TANK#i TANK# 1 Tank passed test in accordance with 527 CMR 9. Yes ❑No ❑ Yes ❑No ❑Yes ❑No ❑ Yes ❑No 2 Pie assed test in accordance with 527 CMR 9.05(H) Yes ❑No ❑ Yes ❑No ❑ Yes ❑No El Yes ❑No 3 Current record of cathodic protection tests on file with ❑ Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No owner or operator. d CP tests performed by: (Company Nance) 5 Is inspection performed after repair of tank/piping? ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No 6 If yes,was cathodic protection system tested/inspected ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑Yes ❑No within 60 days of repair of UST system in accordance with 527 CMR 9.05(H)(6) # � ❑ Pass ❑ Fail ❑ Pass El Fail ❑ Pass ❑Fail ❑ Pass ❑Fail i t . 3 M. L— L If floe answer to arty question is No,please explain belo3v.List any problems noted during inspection.Note corrections on addendum. DuICIENCITS: FURTHER RECOMMENDATIONS: Sectioni Corrosion " i CURRENT CATHODICPROTECTION ANWOR PIPING) TANK�i TANK#i TANKS � TANKtI ` I System has power and is turned on. ITYes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No 2 60-day log is present and filled out properly in ®Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No accordance with 527 CMR 9.05(H) 3 Tank passed test in accordance with 527 CMR UVes ❑No ❑Yes ❑No ❑ Yes ❑No ❑Yes ❑No 9.05(H) 4 Pipe passed test in accordance with 527 CMR rErYes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑Yes ❑No 9.05(H) ' 5 Inspector verifies that inspection results are on file CyWs ❑No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No with local fire department. 6 CP tests performed by: e� n u:ck� `"Ie hh;cc.i ��� r vv Tech n+mil -�ee�n+n�rhl S ce5 svf\/tceS i \r- ' C 7 Is inspection after repair of tank/piping? ❑ Yes ❑No ❑ Yes ❑No []Yes ❑No ❑ Yes ❑No 8 If yes, was cathodic protection system ❑ Yes ❑No ❑ Yes ❑No ❑Yes ❑No ❑Yes ❑No tested/inspected within 60 days of repair of UST s stem in accordance with 527 CMR 9.05(H)(6) t I I 111111 Pass ❑ Fail ❑ Pass ❑Fail ❑ Pass ❑Fail ❑Pass ❑Fail t ' If fire answer to arty question is No,please explain below.List any problems noted riming inspection.Note corrections on addendum. DEMCIENCIFS: 3 FURTHER RE COMIIVIENDATIONS: i 0 g s s g Inspector's Initial Owner/Operator's Initials: Date %(� FP-289 (Rev 9/2009)-Page 12 Date: -7�: v Select Pt-i►nary Method in Seetio►n 5A. A or C. 7r ,,� TANK# TANK# TANK# I JTank assed test in accordance with 527 CMR 9.05(H) No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No 2eassed test in accordance with 527 CMR 9.05(H es ❑ Yes ❑No ❑Yes ❑ No ❑ Yes ❑No 3 Current record of cathodic protection tests on file with ❑ Yes ❑ No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No owner or operator. 4 CP tests performed by: (Company Name) 5 Is inspection performed after repair of tank/piping? ❑Yes ❑No ❑Yes ❑No ❑ Yes ❑No ❑ Yes ❑No 6 If yes, was cathodic protection system tested/inspected ❑ Yes ❑ No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No within 60 days of repair of UST system in accordance with 527 CMR 9.05(H)(6) t ► ❑ Pass El Fail ❑Pass ❑ Fail ❑ Pass El Fail ❑ Pass El Fail Blocks If the annslver to any question is No,please explain below.List only proble►ins rioted during inspection.Note corrections on addendum. DEFICIENCIES: FURTHER RECOMMENDATIONS: Sectioni .: Corrosion PreventiI 'ESSED CURRENT CAT140DIC ' • (TANK ANDHOR TANK# ram-' TANK# TANK# TANK# I System has power and is turned on. Yes ❑No 9�Yes ❑No ❑ Yes ❑No ❑ Yes ❑No 2 60-day log is present and filled out properly in Yes ❑ No �P�Yes ❑No ❑ Yes ❑ No ❑ Yes ❑ No accordance with 527 CMR 9.05(H) Tank passed test in accordance with 527 CMR ff7yes ❑No Yes ❑No ❑ Yes ❑No ❑ Yes ❑No 9.05(H) 4 Pipe passed test in accordance with 527 CMR ffVes LINO Yes ❑No ❑ Yes ❑No ❑ Yes ❑ No 9.05(H) 5 Inspector verifies that inspection results are on file es ❑No Q`Yes ❑No []Yes ❑No ❑ Yes ❑ No with local fire department. 6 CP tests performed by: lfch n tech n�ts� S�.0 di ccs Ser u,t 7 Is inspection after repair of tank/piping? ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑ No 8 If yes, was cathodic protection system ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No ❑ Yes ❑No tested/inspected within 60 days of repair of UST system in accordance with 527 CMR 9.05(H)(6) Section ; Pass ❑ Fail Pass ❑ Fail ❑ Pass❑ Fail ❑ Pass ❑ Fail Blocks ► if applicable, are Yes i -- Ifthe anslver to airy question is No,please explain below.List any problems noted during inspection.Note corrections on addendum. DEFICIENCIES: FuRTIIER RECOMMENDATIONS: Inspector's Initials Owner/Operator's Initials: Date — / FP-289 (Rev 9/2009)- Page 12 Date: — ^�tJ 1n 5.C.: Corrosion Preventi1 •N-METAL CONSTRUCTION MATERIAL TANK TAi�KII TAI�iKIt TAIVKII 1 Tank: Outer wall made of non-metallic material rrE_11 Yes ❑No [IYes ❑No ❑ Yes ❑No ❑ Yes ❑ No such as fiber lass or fiber lass clad steel. 2 Pipe: Outer wall made of non-metallic material Yes ❑No ❑ Yes ❑No ❑ Yes [-]No ❑ Yes ❑No such as fiberglass or corrugated plastic. 3 None of the following conditions were observed in ❑ Yes ❑No ❑Yes ❑No ❑ Yes ❑No ❑ Yes ❑No flexible piping: swelling, elongation,kinking, wrinkling,blistering,delaminating,softness,mold growth,or other abnormalities? Describe in deficiencies below Section 5.C. Passes if ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail © Pass ❑ Fail Blocks ' , if applicable, are Yes If the answer to may question is No,please explain beloly, List may problets►rated tluriitg iiispectioii.Note corrections on addendum. DEFICIENCIES: FURTHER RECOMMENDATIONS: Sectionf Information FACILITY 1 How is water supplied to your facility? ❑ Private Well—Well on Property ❑ Public Water Water Pi ed to Location If private well,answer#2 2 Do you serve water to at least 25 different people at least 60 days of the year? ❑Yes ❑No Lyamples include:providing}rater to drunk frow faucets or bubblers;hm'itng restroonis:serving oi,selling Coffee or other beverages made with,oi,mixed with Ivater. If yes, answer 3,4, 5 & 6 3 Do you have a Public Water System identification number(PWS ID#)fi-om ❑ Yes ❑No MassDEP? 4 If Yes,provide ID#: 5 Verify that location of this well is shown on the sketch in Section 2.C, Cl Yes ❑No marked as DW. 6 Verify Emergency Call List posted with information that there is private ❑ Yes ❑No well on site. Section , Passes if Block , ❑ Pass ❑ Fail ❑Not Apply Not Applicable if Public If(lie answer to any question is No,please explain beloly.List any problems noted during inspection.Note corrections on addendum. DEFICIENCIES' FURTHER RECOMMENDATIONS: Inspector's Initials S Owner/Operator's Initials: 93 Date C3 — lG> FP-289 (Rev 9/2009)-Page I3 Date: -j � ` • 1 � 1 1 � 1 r r jjjZ1FACILITY t � l During thi s inspection,have you identified any releases,leaks,or suspected ❑ Yes YesNo leaks that must be reported to MassDEP per the Massachusetts Contingency Plan 310 CMR 40.0300)? If YES,answer 2,3,&4 2 Date Reported: 3 Time Reported: (Use 24 hour clock) 4 Release Tracking Number(RTN): 5 Has the s stern been taken off-line due to this leak or suspected leak? ❑ Yes No b Was a repair made due to a leak that was reported to MassDEP? ❑ Yes No 7 Source of Release: ❑ Tank ❑ Piping ❑ Dispenser ❑Submersible Turbine Pump ❑Deliver Other: 8 Cause of Release: ❑ Spill ❑ Overfill ❑ Physical/Mechanical Damage ❑ Corrosion ❑ Installation Problem Other: Section1 Pass ❑Pail ❑Not Apply out completely1 ' 1 REPORT ALL SPILLS, LEAKS, OR SUSPECTED LEAKS TO LOCAL FIRE DEPARTMENT AND MASSDEP CALL 888-304-1133 if the answer to an{V question is No,please explain:below. List any problents noted during inspection.Note corrections on addendrun. DEFICIENCIES: FURTHER RECOMMENDATIONS: Section : Comments Use this section to list additional comments not listed in the previous pages. Attach another page if necessary. Owners/operators are required to re or unusual operat' g con itions to MassD T. Were Iny unusual operating conditions ob erved? Inspector's Initials Owner/Operator's Initials: Date FP-289 (Rev 9/2009)-Page 14 Date: ^(� Certification SectionInformation Is a license to store flammables/combustibles posted on site(Form FP-2)? ffYes ❑No ❑NA Is a current certificate of registration posted on site Form FP-5)? El Yes ❑No ❑ NA Is a current permit to maintain USTs posted on site(Forra FP-290 part 3)? Yes ❑No Is the current Form FP-290 accurate?Sec, 1.,4 &2. A.. inust match the FP-290 aYes ❑No Verify that A, B,&C Operators have been trained. EYVes ❑No Attach most recent Form FP-290 E�?'Attached Section i Inspection Section 3.A: Automatic Tank Gauging Pass ❑ Fail ❑Pot Apply Section 3.13: Continuous In-Tank Leak Detection System(CLDS) ❑ Pass ❑ Fail Not Apply Section 3.C: Interstitial Monitoring ❑ Pass ❑ Fail L4 Not Apply Section 3.D: Statistical Inventory Reconciliation(SIR) ❑ Pass ❑ Fail 5f Not Apply Section 3.13: Periodic Tightness Testing ❑ Pass ❑ Fail EtNot Apply Section 3.17: European Suction Pass ❑ Fail ❑ of Apply Section 3.G: Annual Automatic Line Leak Detectors Pass ❑ Fail 5 Not Apply Section 4.A: Spill Prevention Pass ❑ Fail ❑ Not Apply Section 4.13: Overfill Prevention Pass ❑ Fail ❑ Not Apply Section 5.A: Corrosion Prevention—Galvanic Cathodic ❑ Pass ❑ Fail of Apply Section 5.13: Corrosion Prevention—Impressed Current Cathodic Pass ❑ Fail ❑ of Apply Section 5.C: Corrosion Prevention—Non-Metal Construction Material ❑ Pass ❑ Fail 1XNot A ply Section 6: Water Supply Information ❑ Pass ❑ Fail Not Apply Section 7: Reporting of Release, Spill, Suspected Leaks Pass ❑ Fail ❑Not Apply 1, the Certified Inspector, have performed this UST 1, the Owner/Operator (circle one), have read this Inspection and believe the contents of this report to be true Inspection Report and have been told the condition of illy and accurate at the time of inspection. I also have no UST facility, including all deficiencies, corrections and significant financial interest with this UST, recommendations. All aj2plicable pages are initiated caw/ Facility# /� 4 5 (fill ill), included in this submittal. Print Name: Print Name: ��`�rP r C� Signature: Signature: E-Mail: .4 `GOri7 fw rAlyle , 0o1w E-Mail: Phone: G 17- 62 fj 2-C Phone LDS,3 3 )31 _____Date: R-- ;I- P Inspector ID #: 14Ly3 Date: MAIL COMPLETED FORMS DEPARTMENT ENVIRONMENTAL.PROTECTION NO LATER THAN BUREAU OF WASTE PREVENTION-UST PROGRAM 14 DAYS P. 0.BOX 120-0165 FROM THE DATE BOSTON MA 02112-0165 OF THE INSPECTION TO: AND SEND COPY TO LOCAL FIRE DEPARTMENT Inspector's Initials Owner/Operator's Initials: Date FP-289 (Rev 9/2009)-Page 15 Date: "7- i10-. Addendum Facility Name: DEP Facility ID Number: I I Required Use this section to note any deficiency corrections or repairs that were made after the initial inspection. The UST third-party Inspection should be a `snapshot' completed prior to any repairs or adjustments that would affect whether or not a UST would pass or fail. List each corrected item separately. If you have any questions,please call the MassDEP UST office at 617-556- 1053. Use additional copies of this page if necessary. Item 1. Date of Work: Tank or Pipe#: is now: PASS OR FAIL the Inspection(circle one) Description of Repair or Deficiency Correction: UST Worker Name: UST Worker Signature: Date Item 2. Date of Work: Tank or Pipe#: is now: PASS OR FAIL the Inspection(circle one) Description of Repair or Deficiency Correction: UST Worker Name: UST Worker Signature: Date Item 3. Date of Work: Tank or Pipe#: is now: PASS OR FAIL the Inspection(circle one) Description of Repair or Deficiency Correction: UST Worker Narne: UST Worker Signature: Date Item 4. Date of Work: Tank or Pipe#: is now: PASS OR FAIL the Inspection(circle one) Description of Repair or Deficiency Correction: UST Worker Naine: UST Worker Signature: Date MAIL COMPLETED FORMS DEPARTMENT ENVIRONMENTAL PROTECTION NO LATER THAN BUREAU OF WASTE PREVENTION-UST PROGRAM 14 DAYS P. O.Box I20-0165 FROM THE DATE BOSTON MA 02112-0165 OF THE INSPECTION TO: AND SEND COPY TO LOCAL FIRE DEPARTMENT Inspector's Initials Owner/Operator's Initials: Date FP-289 (Rev 9/2009)- Page t6 Date: -�—