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APPENDIX r r UNDERGROUND STORAGE SYSTEM INSPECTION <br /> Go to www.pei.orgIRP900 for an electronic version of this form. <br /> Category Description POlRP9tro N/A Taec1 Taee2 Tak3 Tank <br /> Continuous Soil <br /> Vapor Monitoring Sensing deNce tested TEST DATE: 8.11.7.1 <br /> ConlinuousG.round- Sensing device tested TEST DATE: 8.11.8.1 <br /> water Monitoring <br /> Corrosion Protection 8.12 <br /> Galvanic Verify that cathodic protection testing of all metallic <br /> Cathodic components in contact with soil or water has been conducted TEST DATE: 8.12.1.1 <br /> Protection within the past 3 years and the test passed <br /> Impressed Verify that cathodic protection testing has been conducted TEST DATE: 8.12.2.1 <br /> Current Cathodic `Within the past 3 years and the test passed <br /> Protection No exposed wires 8.12.2.2 <br /> Tank Lining Lining inspected as required and in good condition TEST DATE: 8.12.3.1 <br /> Miscellaneous Inspection Items 8.13 <br /> Tank Pad& Concrete or asphalt over or near tanks is level,no significant cracks 8.13.1.1 <br /> Pavement <br /> Stage II Liquid Cap in good condition,fits tightly,little or no liquid in bottom 8.13.2.1 <br /> Collection Points <br /> Stage I Testing Verifyfssm Stage I testing has been conducted and test results TEST DATE: 8.13.3.1 <br /> Stage Wresting esus are <br /> Stage 11 testing has been conducted and test TEST DATE: 8.13.4.1 <br /> pawing I <br /> Site Diagram Site diagram accurately reflects the site conditions 8.13.5.1 <br /> DESCRIBE ANY DEFICIENCIES HERE: <br /> Instructions: Mark each tank where no problem is observed with a checkmark: q If certain equipment is not required and i or not present, mark checklist in the NIA <br /> column.Its defect is found, mark the checklist with an'X,'describe the problem in the'DEFICIENCIES'section,and notify the appropriate person.Refer to the <br /> section listed in the'PEURP900'column for additional information.Refer to PEI RP500,Recommended Practices for Inspection and Maintenance of Motor Fuel <br /> Dispensing Equipment,for inspection procedures that apply to fuel dispensing equipment. <br /> PEI RP 900 Annual Inspection Checklist Page—of_ <br />