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APPENDIX A-3: SAMPLE FORM , - ANNUAL STP INSPECTION <br /> Go to www.pei.orgIRP900 for an electronic version of this form. <br /> I D# ANNUAL STP INSPECTION CHECKLIST Date: <br /> Category IDescription PEIM"W N/A Tank I Tank Timk 3 Taec4 <br /> Submersible Turbira Pump(STP) <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 /> Junction boxes)have covers,not corroded;conduit and intrinsically safe wiring in good condition 8.6.8 <br /> Flexible connectors not frayed,twisted, kinked or bent beyond manufacturer specifications 8.6.9 <br /> All STP Mechanical line leak detector properly vented,vent tube not kinked or twisted,vent tube fittings 86.10 <br /> intact and tightened <br /> Mechanical line leak detector passes 3.0 gallons per hour(gph) TEST DATE: 8.6.11 <br /> test <br /> Electronic line leak detector(ELLD)passes 3.0 gph test TEST DATE: 8.6.12 <br /> ELLD passes 0.2 gph test TEST DATE: 8.6.13 <br /> ELLD passes 0.1 gph test TEST DATE: 8.6.14 <br /> Manhole cover at grade in good condition,does not touch sump cover,all bolts present,handles 8.6.24 <br /> and lift mechanism in good condition as applicable) <br /> STPNa Submersible pump head,flex connectors)and other metallic product piping are not in contact with <br /> Containment soil or water or are catholically protected 8'6'17 <br /> Sum <br /> Any water or product removed and disposed of properly 8.6.4 <br /> Sump is free of cracks, holes,bulges or other defects 8.6.6 <br /> STP:In Penetration fittings intact and secured 8.6.7 <br /> Containment <br /> Sump Piping interstitial space open to the STP sump(open double-walled piping system only) 8.6.20 <br /> Piping interstitial space closed to the STP 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 /> F <br /> :InlledSingle walled sump tested for integrity every 3 years TEST DATE: 8.6.18 <br /> entm <br /> PEI RP 900 Annual STP Inspection Checklist Page_of_ <br />