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li4a d Hwy IQN rBvar-ct,..I IUili RECORD <br />FACILIT7 NAME: ADDRESS:` <br />Sti`EE?Slt TAl" ULP TANK TERIAL: <br />tAPACITY: PRODUCT: R.E.H.S: <br />INITIAL INSPECTIONS <br />A <br />I <br />3. INSPECTION AM TEST OF SECONDARY CONTAIXPIENT: HOLIDAY: <br />VACUUM: I SOAP. PSI: NRS/MIN: BRINE(LIQUID ): arHER: <br />P <br />N <br />ALL TAMILS TO BE INSTALLED AND TESTED IN ACCORDANCE <br />4. PRIMARY TANK TEST: PSI: NRS/MIN: <br />P <br />I <br />WITH MAMUFACIURSt WRITTEN SPECIFICATIONS <br />5. TANK APPROPRIATELY PLACED WITH APPROVED BACKFILL (CCA 2635 CA) (3) (A) (6)/ API/PEI) <br />R <br />T <br />9, UNUSED TANK OPENINGSION PROTECTED ( ) <br />0 <br />I <br />10. OVERSPILL PERFORMANCE TEST (Cat 2635 (A) 06)) <br />V <br />A <br />11. ALL PIPING AMD FITTINGS CORROSION PROTECTED (CCR 2635 (8)) <br />E <br />L <br />18. TANK ACCESS PORTS BROUGHT TO GRADE (LOCKED AND WATERTIGHT) CCt7R 2631 (D) (5)) <br />0 <br />S <br />19. TANK INTEGRITY TEST (PASSING HARD COPY) (CCR 2635 CA) (5)) <br />ITEM OR EQUIPMENT INSPECTED <br />DATE <br />21. "C" FORM! COMPLETED AND SUBMNITTED (CCR 2635 (E3) <br />1. UST PLANS SUBMITTED/ FEES PAID CH+S CODE 25287. CCA 2M5 (D) (8) <br />2_ UST INSTALLATION PLANS APPROM (CCR 2655 (E) (5)) <br />INITIAL INSPECTIONS <br />PIPING INSPECTIONS <br />3. INSPECTION AM TEST OF SECONDARY CONTAIXPIENT: HOLIDAY: <br />VACUUM: I SOAP. PSI: NRS/MIN: BRINE(LIQUID ): arHER: <br />7. SECONDARY PIPING CONTAINMENT TEST PSI: HRS/MIN: OTHER: (CCR 2635 (A) (4)) <br />4. PRIMARY TANK TEST: PSI: NRS/MIN: <br />8. LAKE TEST ON ALL SUMPS (24 NR_ MINIMA) HRS: (CCR 2635 CA)) <br />5. TANK APPROPRIATELY PLACED WITH APPROVED BACKFILL (CCA 2635 CA) (3) (A) (6)/ API/PEI) <br />PIPING INSPECTIONS <br />FINAL LMSPECTICV <br />6. PRIMARY PIPING TEST (MINIMUM 40 PSI/30 AIN) (CCR 2635 (B) (4)) <br />7. SECONDARY PIPING CONTAINMENT TEST PSI: HRS/MIN: OTHER: (CCR 2635 (A) (4)) <br />8. LAKE TEST ON ALL SUMPS (24 NR_ MINIMA) HRS: (CCR 2635 CA)) <br />9, UNUSED TANK OPENINGSION PROTECTED ( ) <br />10. OVERSPILL PERFORMANCE TEST (Cat 2635 (A) 06)) <br />11. ALL PIPING AMD FITTINGS CORROSION PROTECTED (CCR 2635 (8)) <br />FINAL LMSPECTICV <br />COPO ENTS: <br />EH23-006 3/92 <br />12. PERFORMANCE TEST FOR `ALL• MONITORING PROBES (CCR 2632 (C) C23) <br />13. PERFORMANCE TEST OF CONTINUOUS MONITORING SYSTEM# (PANEL) (CCR 263- CA) (2)) <br />14. PERFORMANCE TEST OF LINE LEAK DEMO ON (t7CR 2632 (D) 2635 (S) (5)) <br />15. PERFORMANCE TEST OF At1TOMATIC PRIMP SYSTE]1 mw -OFF (CCR 2635 (8) (5)) <br />16. BALL FLOAT VALVES INSTALLED (CCt 2635 (8) (6)) <br />17. OVERFILL PROTECTI(IN IILSTALLED/ c= 2635 (E) C23) <br />18. TANK ACCESS PORTS BROUGHT TO GRADE (LOCKED AND WATERTIGHT) CCt7R 2631 (D) (5)) <br />19. TANK INTEGRITY TEST (PASSING HARD COPY) (CCR 2635 CA) (5)) <br />20- MONITORING PLAN, REWKKSE PLAN AND LOG BCJCDK 00 SITE (CCR 2632 (E) (1) C23) <br />21. "C" FORM! COMPLETED AND SUBMNITTED (CCR 2635 (E3) <br />22_ MONITORING METHOD FOR ALL TANKS AND PIPING APPROVED CCCR 261.1-26;4) <br />23. ALL CONDITIONS MET; FACILITY PERMIT 1" 1:11 (LMS CODE 25284 (E) CM <br />COPO ENTS: <br />EH23-006 3/92 <br />