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APPENDIX A-3: SAMPLE FORM FOR ANNUAL UNDERGROUND STORAGE SYSTEM INSPECTION CHECKLIST — page I <br /> Go to www.pei.orgIRP900 for an electronic version of this form. <br /> ANNUAL UST SYSTEM INSPECTION CHECKLIST <br /> Facility ID# Facility Name/Address Qualified Technician Signature Date <br /> If any problem isfound, contact: Contact information: <br /> Category Description PERP900 N/A Tank Tank Tak3 Tank <br /> Monthly Complete monthly checklist and compare to previously completed monthly checklists 8.4.1 <br /> Inspections Monthly inspections reviewed and found adequate 8.4.2 <br /> ATG Manhole 8.8 <br /> Cap in good condition,seals tightly,hole sealed where probe We goes through 8.8.1 <br /> Wire splices sealed and wire in good condition 8.8.2 <br /> Junction box has cover, not corroded;intrinsically safe wiring in good condition 8.8.3 <br /> No exposed wires 8.8.4 <br /> ATG Manhole Probe and floats in good condition,both floats present and <br /> move free)y(mag probe) TESTDATE: 8.8.5 <br /> Verity functionality of ATG probe TEST DATE: 8.8.8 <br /> Manhole cover in good condition 8.8.7 <br /> Adequate clearance between ATG grade-level cover and below-grade components 8.8.8 <br /> Fill Area 8.9 <br /> Drop Tube Drop tube extends to within 8 inches of the tank bottom (if no flow diffuser present) 8.9.1 <br /> Vapor Recovery Poppet of Stage I vapor recovery adaptor(also known as a`dry break')moves freely,seals 8.9.2 <br /> Adaptor tightly <br /> Single-Walled <br /> nt Singlewalled spill containment manhole tightness tested <br /> Spill Containment within last 3 years TEST DATE: 8.9.3 <br /> Manhole <br /> Double-Walled Doublewalled spill containment manhole tightness tested <br /> Spill Containment within last 3 years OR inspected monthly TEST DATE: 8.9.4 <br /> Manhole <br /> Overfill Prevention 8.10 <br /> Drop Tube Drop tube shutoff valve passes inspection EVALUATION DATE: 8.10.1.1 <br /> Shutoff <br /> (Flapper Valve) For drop tube shutaff valves in diesel tanks,excessive corrosion not present 8.10.1.2 <br /> PEI RP 900 Annual Inspection Checklist Page_of_ <br />