DERR-2024-012656

AST Annual Visual Inspection Checklist
(Revised 05/11/2023)
Facility ID#: Facility Name: Inspection Date:
Street Address: City: ZIP:
# of Tanks Inspected: Tank ID Numbers:
Any item marked “No” requires additional information to describe the condition and date the condition is corrected.
ITEM STATUS COMMENTS / DATE CORRECTED
Containment
1 Is the containment structure in satisfactory condition
(diking, impounding, double-wall tank, etc.)? Yes No
2 Are the drainage pipes/valves in good working
condition for continued service? Yes No N/A
Tank Foundation/Supports
3 Free of tank settlement or foundation washout? Yes No
4 Concrete pad or ring wall free of cracking or spalling? Yes No
5 Tank supports in satisfactory condition? Yes No
6 Is water able to drain away from tank? Yes No
7 Is the grounding strap between the tank and
foundation/supports in good condition? Yes No N/A
Cathodic Protection
8 Are cathodic protection system in operating condition
and functional? Yes No N/A
9
Rectifier reading
Volts: ________ Amps: _______
Are these readings within manufacturer
specifications?
Yes No N/A
Tank External Coating
10 Free of visible signs of paint failure? Yes No
Tank Shell / Heads
11 Free of noticeable shell/head distortions, buckling,
denting, or bulging? Yes No
12 Free of visible signs of shell/head corrosion or
cracking? Yes No
Tank Manways, Piping, and Equipment
13 Flanged connection bolts tight and fully engaged with
no sign of wear or corrosion? Yes No N/A
Tank Roof
14 Free of standing water on roof? Yes No
15 Free of visible signs of coating cracking, crazing,
peeling, or blistering? Yes No
16 Free of holes? Yes No
AST Annual Visual Inspection Form Page 1 of 2
Pilot Thomas #109 10-12-24
350 N. Vernal Ave.Vernal 84078
3 DSL, REG, PRM
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
ITEM STATUS COMMENTS/DATE CORRECTED
Venting
17 Normal and emergency vents free of obstructions? Yes No
18 Normal vent on tanks storing gasoline equipped with
pressure/vacuum vent cap? Yes No N/A
19 Is the emergency vent in good working condition and
functional, and tested as required by manufacturer? Yes No
Insulated Tanks
20 Free of missing insulation? Yes No N/A
21 Insulation free of noticeable areas of moisture? Yes No N/A
22 Insulation free of mold? Yes No N/A
23 Insulation free of visible signs of damage? Yes No N/A
24 Insulation adequately protected from water
intrusion? Yes No N/A
Level and Overfill Prevention Equipment
25 Electronic or mechanical liquid level gauge tested for
proper operation? Yes No N/A
26 Electronic or mechanical liquid level gauge calibrated
during the previous 12 months? Yes No N/A
27
Is overfill prevention equipment in good working
condition?
Overfill Valve Audible Alarm Both
Yes No N/A
Verified
by:
Inspection
Date:
Operational?
Yes
No
Repair
Date:
28 Is tank ullage being determined and documented
before filling the tank? Yes No N/A
Electrical Equipment
29 Is tank/equipment grounding adequate and in good
condition? Yes No
30 Is electrical wiring for control boxes, lights, and other
high voltage equipment in good condition? Yes No N/A
Additional Comments
Inspector Information (Certified Individual or Professional Engineer)
Printed Name: Signature: Date:
AST Annual Visual Inspection Form Page 2 of 2
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4
Max LaRou UT-412 10/12/2024
EZY CHEK SYSTEMS TEST DATE
PRODUCT LINE TESTER Testing Company Information
DATA SHEET Name
Address
City
Test Location Information
Precision Testing Technologies, Inc.
2026 W. Elk Creek Crt.
Bluffdale, UT
Test Location Information Phone
Name
Address Technican Information
City Name
Phone Cert #
801-886-9224
Contact
Applied Pressure
#1 Product Type:#2 Product Type:
TIME DATA -/+GPL RES GPH TIME DATA -/+GPL RES GPH
0 0.0037 0.0000 0.0000 0 0.0037 0.0000 0.0000
0.0037 0.00370.0037 0.0037
0.0037 0.0037
0.0037 0.0037
0.0037 0.0037
0.0037 0.0037
FINAL RESULT:FINAL RESULT:
#3 Product Type:#4 Product Type:
TIME DATA -/+GPL RES GPH TIME DATA -/+GPL RES GPH
0 0.0037 0.0000 0.0000 0 0.0037 0.0000 0.0000
0.0037 0.0037
0.0037 0.0037
0.0037 0.0037
0.0037 0.00370.0037 0.0037
0.0037 0.0037
FINAL RESULT:FINAL RESULT:
#5 Product Type:#6 Product Type:
TIME DATA -/+GPL RES GPH TIME DATA -/+GPL RES GPH
0 0.0037 0.0000 0.0000 0 0.0037 0.0000 0.000000.0037 0.0000 0.0000 0 0.0037 0.0000 0.0000
0.0037 0.0037
0.0037 0.0037
0.0037 0.0037
0.0037 0.0037
0.0037 0.0037
FINAL RESULT:FINAL RESULT:
Facility ID#
:
10/12/2024
Pilot Thomas #109
350 N. Vernal Ave.
Vernal, UT 84078 Max LaRou
UT-412
55 P.S.I.
REG
0 71
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0 52
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0 29
15 29 0 0 0
30 29 0 0 0
PASS
10/12/2024
Max LaRou
UT-412
pei.org 43
Recommended Practices for the Testing and Verification of Spill, Overfill, Leak Detection and Secondary Containment Equipment at UST Facilities
APPENDIX C-3
SPILL BUCKET INTEGRITY TESTING HYDROSTATIC TEST METHOD
SINGLE AND DOUBLE-WALLED VACUUM TEST METHOD
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Precision Testing Technologies Inc.801-886-9224
Pilot Thomas #140
10/12/2024
1
CLR DSL
15 Gal.
Morrison Bros.
4
4
4
4
4
4
4
4
5.5"
0 Min.
5.5"
60 Min.
60 Min.
0
4
2
DYE DSL
15 Gal.
Morrison Bros
4
4
4
4
4
4
4
4
5.5"
0 Min.
5.5"
60 Min.
60 Min.
0
4
3
CLR DSL Truck
15 Gal.
Morrison Bros.
4
4
4
4
4
4
4
4
5.5"
0 Min.
5.5"
60 Min.
60 Min.
0
4
4
CLR DSL Auto
15 Gal.
Morrison Bros.
4
4
4
4
4
4
4
4
5.5"
0 Min.
5.5"
60 Min.
60 Min.
0
4
5
PRM
15 Gal.
Morrison Bros.
4
4
4
4
4
4
4
4
5.5"
0 Min.
5.5"
60 Min.
60 Min.
0
4
6
REG
15 Gal.
Morrison Bros.
4
4
4
4
4
4
4
4
5.5"
0 Min.
5.5"
60 Min.
60 Min.
0
4
Max LaRou UT-412