Cal. Code Regs. Tit. 23, div. 3, ch. 16, app XIII

Current through Register 2024 Notice Reg. No. 49, December 6, 2024

Appendix XIII - Underground Storage Tank Designated UST Operator Visual Inspection Report

1. FACILITY INFORMATION

CERS ID		Inspection Date
___________________________
Facility Name
___________________________
Facility Address	City	ZIP Code
___________________________

2. DESIGNATED UST OPERATOR INFORMATION

Name of Designated UST Operator	Phone
___________________________
ICC Certification	Certification Expiration Date
___________________________

3. COMPLIANCE ISSUES

Identify by number all compliance issues listed

4. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING INSPECTION

I hereby certify that the visual inspection was performed in compliance with California Code of Regulations, title 23, division 3, chapter 16, section 2716 and all information provided herein is accurate.

Designated UST Operator Signature

CERS = California Environmental Reporting System, ICC = International Code Council, ID = Identification, NA = Not Applicable, UDC = Under-Dispenser Containment, UST = Underground Storage Tank

5. OWNER/OPERATOR DESCRIPTION OF FOLLOW-UP ACTION

Number the follow up actions to correspond to appropriate compliance issues from Section 3.

6. OWNER / OPERATOR ACKNOWLEDGEMENT OF INSPECTION RESULTS

I have reviewed the results of the designated UST operator inspection report and provided a description of the action(s) taken or to be taken to correct any compliance issues discovered.

Name of UST Owner / Operator (print)
___________________________
UST Owner/Operator Signature	Date Signed
___________________________

7. INSPECTION HISTORY

Has each follow-up action of Section 3 from the previous Designated UST	Yes	No	NA
Operator Inspection Report been completed appropriately?	[]	[]	[]
(Attach documentation verifying appropriate service to this report.)

8. RELEASE DETECTION ALARM HISTORY

Attach a copy of the alarm history report/log to this report.	Yes	No	NA
Is the monitoring system powered on and in proper operating mode?	[]	[]
Has each alarm since the previous inspection been responded to appropriately?
(Attach documentation verifying appropriate service to this report.)	[]	[]	[]
Have all containment sumps, that have had an alarm since the previous designated UST operator inspection report, been responded to by a qualified service technician?	[]	[]	[]
All answers marked "No" must be described by the designated UST operator in Section 3.

9. UST SYSTEM INSPECTION

List below and in Section 3 all containment sumps that have had a release detection alarm since the previous Designated UST Operator Inspection Report and have not been responded to by a qualified service technician. Containment sumps listed below require a visual inspection for damage, water, debris, hazardous substance, and proper sensor location.

Is the containment sump free of damage, water, debris, and hazardous substances?

Containment Sump ID	Yes	No	Containment Sump ID	Yes		No
___________________________	[]	[]	___________________________	[]		[]
___________________________	[]	[]	___________________________	[]		[]
Are all sensors in visually inspected containment sumps located to detect a release at the earliest opportunity?					[]	[]

Is the spill containment free of damage, water, debris, and hazardous substances? Is the fill pipe free of obstructions? Is fill cap securely on the fill pipe?

Spill Containment ID	Yes	No	Spill Containment ID	Yes	No
___________________________	[]	[]	___________________________	[]	[]
___________________________	[]	[]	___________________________	[]	[]
___________________________	[]	[]	___________________________	[]	[]
___________________________	[]	[]	___________________________	[]	[]

Is the UDC free of damage, water, debris, and hazardous substances and all sensors located to detect a release at the earliest opportunity?

[] No UDC(s) at this facility

UDC ID	Yes	No	UDC ID	Yes	No
___________________________	[]	[]	___________________________	[]	[]
___________________________	[]	[]	___________________________	[]	[]
___________________________	[]	[]	___________________________	[]	[]
___________________________	[]	[]	___________________________	[]	[]
___________________________	[]	[]	___________________________	[]	[]
___________________________	[]	[]	___________________________	[]	[]
___________________________	[]	[]	___________________________	[]	[]

[]Mechanical float mechanisms used in UDCs.

All answers marked "No" must be described by the designated UST operator in Seciton 3.

10. TESTING AND MAINTENANCE	Yes	No	NA	Date last performed
Has monitoring system certification been completed within the past 12 months?	[]	[]
Has spill container testing been completed within the past 12 months?	[]	[]
Has overfill prevention equipment inspection been completed within the past 36 months?	[]	[]	[]
Has secondary containment testing been completed within the past 36 months?	[]	[]	[]
Has tank tightness testing been completed within required timeframes?	[]	[]	[]
Has line tightness testing been completed within the required timeframes?	[]	[]	[]
Other Test / Maintenance:	[]	[]	[]
Other Test / Maintenance:	[]	[]	[]
Other Test / Maintenance:	[]	[]	[]

11. FACILITY EMPLOYEE TRAINING	Yes	No
Have all individuals performing facility employee duties received the required facility employee training within the past 12 months?	[]	[]

13. COMMENTS

This section may be used to record comments or observations that are not current compliance deficiencies.

All answers marked "No" must be described by the designated UST operator in Section 3.

Cal. Code Regs. Tit. 23, div. 3, ch. 16, app XIII

1. New Appendix XIII filed 8-27-2018; operative 10-1-2018 (Register 2018, No. 35).
2. Repealer and new appendix filed 8-27-2020; operative 10-1-2020 (Register 2020, No. 35). Filing deadline specified in Government Code section 11349.3(a) extended 60 days pursuant to Executive Order N-40-20 and an additional 60 days pursuant to Executive Order N-66-20.

1. New Appendix XIII filed 8-27-2018; operative 10/1/2018 (Register 2018, No. 35).