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APPENDIX A-3: SAMPLE FORM FOR ANNUAL FILL CONTAINMENT SUMP INSPECTION CHECKLIST <br /> Go to www.pei.orgIRP900 for an electronic version of this form. <br /> ID#: ANNUAL FILL CONTAINMENT SUMP INSPECTION CHECKLIST Date: <br /> Category IDescription PEMP900 N/A Tank Tank Tank Tank4 <br /> Fill Sump 8.6 <br /> Anywater or product removed and disposed of properly 8.6.4 <br /> Visible piping and fittings show no signs of leaking 8.6.1 <br /> Piping in good condition 8.6.2 <br /> Excessive corrosion not present 8.6.3 <br /> Sump free of trash and debris 8.6.5 <br /> Sump is free of cracks, holes,bulges or other defects 8.6.6 <br /> Fill Containment Penetration fittings intact and secured 8.6.7 <br /> Sump <br /> Junction boxes)have covers,not corroded;conduit and intrinsically safe wiring in good 8.6.8 <br /> condition <br /> Flexible connectors not frayed,twisted, kinked or bent beyond manufacturer specifications 8.6.9 <br /> Piping interstitial space open to the fill sump (open double-walled piping system only) 8.6.20 <br /> Piping interstitial space closed to the fill sump(closed double-walled piping system only) 8.6.22 <br /> Sump lid,gasket and seals present and in good condition 8.6.23 <br /> Manhole cover at grade in good condition,does not touch sump cover,all bolts present, 8.6.24 <br /> handles and lift mechanism in good condition(as applicable) <br /> Single-Walled Single-walled sump tested for integrity every 3 years TEST DATE: 8.6.18 <br /> Fill Sum <br /> Double-Walled If not continuously monitored or inspected annually,double-walled TEST DATE: 8.6.19 <br /> Fill Sump sump tightness tested every 3 years <br /> DESCRIBE ANY DEFICIENCIES HERE: <br /> PEI RP 900 Annual Fill Sump Inspection Checklist Page_of_ <br />