Storage Tank System Leak Autopsy Report Form - Storage Tanks

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Storage Tank System Leak Autopsy Report Form - Storage Tanks Powered By Docstoc
					                   Storage Tank System Leak Autopsy Report Form
                               Please check all blocks that apply for the entire form

                                                 Site Information

 Facility Name                  Facility ID Number              County              Owner/Operator Name



                                 System Information (At the Time of Release)
Tank

 Tank Type
  Underground Storage Tank
  Shop-fabricated Aboveground Storage Tank
  Field-erected Aboveground Storage Tank

 Tank Installation Date:____________________________________          (Note if Unknown)
 Tank Manufacturer Name:_________________________________              (Note if Unknown)
 Piping Installation Date___________________________________           (Note if Unknown)
 Piping Manufacturer Name:________________________________            (Note if Unknown)

                                               System Information
                               Please check all blocks that apply for the entire form
USTs

       Material                     Other Attributes                                        Ancillary Equipment
      Galvanized Steel            Sacrificial Anodes                                     Spill Containment Bucket
      Fiberglass                  Impressed Current System                               No Spill Containment
      Composite                   Internal Lining                                        Unknown
      Unprotected Steel           Single Wall                                             Overfill Protection
      Other Approved              Double Wall (same material)                            Ball Check Valve
      Concrete                    Double Wall (different material)                       Flow Shut-Off
      Polyethylene                Secondary Containment with a liner                     Tight Fill
      Unknown                     Other Approved (Tank Bladders, etc.)                   Alarm System
                                  Compartmented                                          No Overfill Protection
                                                                                         Unknown

ASTs

       Material                     Other Attributes                                        Ancillary Equipment
      Steel                       Shop-Fabricated                                         Overfill Protection
      Concrete                    Field-Erected                                          Flow Shut-Off
      Polyethylene                Synthetic liner beneath tank (SC)                      Alarm System
      Approved Synthetic          Concrete beneath tank (SC)                             Gauges
      Other Approved              Double Wall                                            Other Approved
      Cut and Cover               Internal Secondary Containment                         No Overfill Protection
      Unknown                     Other Approved Secondary                               Spill Cont. (for Shop-
                                    Containment                                             Fabricated Tanks)
                                   Single Wall                                            No Spill Containment

                                   Impressed Current System                            
                                   Synthetic Dike Field Liner
                                   Concrete Dike Field Liner
                                   Other Approved Dike Field Liner
                                   Secondary Containment around
                                    pumps/valves
                                   No Dike Field Secondary
                                    Containment
Piping – AST or UST

       Material                     Other Attributes                                        Ancillary Equipment
    Galvanized Steel                 Sacrificial Anodes                                    Dispenser Sump(s)
    External Coating                 Impressed Current System                              No Dispenser Sumps
    Fiberglass                       Single Wall                                           Unknown
    Composite                        Double Wall (same material)                           Piping Sump(s)
    Unprotected Steel                Double Wall (different material)                      No Piping Sumps
    Flexible Synthetic               Secondary Containment with a liner                    Unknown
    Other Approved                   Other Approved Secondary                              Single check valve
                                       Containment
    Unknown                          Box-trench Liner                                      Foot Valves
                                      Pressurized                                           Unknown
                                      Not-Pressurized except when in use                    Mechanical Line Leak
                                                                                              Detector (LLD)
                                      Suction                                               Electronic LLD
                                      Manifolded                                            Unknown
                                      Bulk Product                                          No Line Leak Detector
                                      Small Diameter
                                      Hydrant System
                                      Aboveground, no contact with soil
                                      Over Surface Water

Leak Detection

     UST                                      AST                                            Piping
    Internal Interstitial                   Interstitial Monitoring                       Interstitial Monitoring
     Monitoring
    Interstitial Monitoring                 Groundwater Monitoring Wells                  Groundwater Monitoring
     within a liner system                                                                   Wells
    Groundwater Monitoring                  Vapor Monitoring Wells                        Vapor Monitoring Wells
     Wells
    Vapor Monitoring Wells                  Vapor Monitoring Probes                       Vapor Monitoring Probes
    SIR                                     Tracer Technology                             Tracer Technology
    ATG                                     Visual Inspections                            Visual Inspections
    Tank Tightness Testing                  Cable Systems                                 Cable Systems
    Inventory Reconciliation                Fiber-optic Technologies                      Pressure Tests (Bulk)
    Manual Tank Gauging                     SPCC Plans                                    Pressure Tests (Small)
    Visual Inspections                      Tank Shell Monitoring System                  Mechanical Line Leak
                                                                                             Detectors
    Other Approved Methods                  Other Approved Methods                        Automatic Line Leak
                                                                                             Detectors
                                                                                          Other Approved Methods

                                                 Release Information

 Date of receipt of test results or discovery of confirmed discharge: __________________________month/day/year
 Estimated number of gallons discharged:_______________                   Latitude and Longitude_____________________

Discharge affected

    Air                                                           Drinking water well(s)
    Soil                                                          Surface water
    Ground water                                                  Other________________________________

Type of regulated substance discharged: (check one)

    Gasoline                                                      Used/waste oil
    Diesel                                                        New/lube oil
    Kerosene                                                      Mineral acid
    Jet fuel                                                      Petroleum Contact Water
    Aviation gas                                                  Pesticides
    Gasohol                                                       Chlorine Compounds
    Emergency Generator Diesel Fuel                               Ammonia Compounds
    Heating oil                                                   Petroleum Derivative Products
    Hazardous substance                                           Other
    Grades 5 & 6 Residual Oils                                    Unknown

Method of Discovery of the Discharge
  Leak Detection Methods                  ***If Leak Detection, specify method:
          Closure-in-Place                           Inventory Reconciliation                 Mechanical LLD
          Removal                                    Manual Tank Gauging                      Electronic LLD
          Installation or Upgrade                    Groundwater Monitoring                   Visual Inspection of ASTs
          Property Transfer                                                                
          Visual                                     Vapor Monitoring                         Visual Inspection of USTs
          Olfactory                                  Secondary/Interstitial                   Tracer technologies
                                                       Monitoring
          Water in Tank                              Annual or Regularly                      Bulk Product Piping
                                                       Scheduled Tank                            Pressure Tests
                                                       Tightness Testing
          Tank or LineTightness                      Annual or Regularly                      Fiber-Optic or Cable
           Testing Performed for other                 Scheduled Line                            Technologies
           Reasons_______________                      Tightness Testing
          Internal Inspection                        SIR                                      Other Approved Methods
          Unknown                                    ATG                                      Vapor Monitoring Probes
          Other ____________________                 Analytical tests or samples              Other_______________


           Did the method of Leak Detection relied on for compliance purposes fail to detect the release? (Y,N, U)
           If so, what was the method relied on for compliance purposes?___________________________________

      Source of Discharge:
        UST                                                              Shop-Fabricated AST
        Small Diameter Piping                                            Field-erected AST
        Flex-Connector                                                   Bulk Product Piping
        UST Vent Line                                                    Pipeline
        UST Fill Pipe                                                    Valves (ASTs)
        UST Turbine Pump                                                 Pump (ASTs)
        Dispenser                                                        Barge or Vessel
        Delivery Vehicle                                                 Bulk Product Dock Piping (connected to ASTs)
        UST Electronic/Mechanical Line Leak Detector                     Hydrant Pit (AST systems)
           Other _______________                                          AST Vents

      Cause of the Discharge
        Loose Component (filter, piping connection, bung, etc)                         Improper Installation
        Corrosion                                      Spill                          Vehicle Accident
        Puncture                                       Overfill                       Physical or Mechanical Damage
        Material Failure (crack, split, etc.)          Weather                        Human Error
        Material Incompatability                       Unknown                        Vandalism or Malicious Intent
        Other _____________________________                                            Fire/Explosion

      Release Identified by:

          Owner/Operator                            Service Contractor                     Local Government Inspector
          Third Party                               State Inspector                        Other

      Additional Information: (Attach Photos if available)




SIGNATURE:_________________________________________                AFFLILIATION:_______________________________________