ABOVEGROUND STORAGE TANK MONTHLY VISUAL INSPECTION FORM

Facility Name: Enter name here PBS Facility No:

SCDOH : 30045
Street Address: Use either this form or its equivalent to document
1 ABC Drive monthly visual inspections required by 613.6 of
AnyTown, NY 11234 6NYCRR PBS regulations.
Records MUST be maintained for ten years.

Please check the proper box for the associated tank and piping. If a checked box is in bold font, then
describe the deficiency and record the action taken to correct the problem and expected date of work to be
performed to meet compliance in the space below.

Item 275 gallon

Tank #10
Visible leaks on tanks, tank seams, Yes No Yes No Yes No
connections, fittings or valves
Visible leaks on piping, piping seams, Yes No Yes No Yes No
connections, fittings, flanges, threaded
connections, pumps or valves
Overfill equipment in good operating Yes No Yes No Yes No
condition

Evidence of corrosion on tanks, piping Yes No Yes No Yes No

and valves
Excessive settlement of structures Yes No Yes No Yes No
Malfunctioning equipment (ie/: Yes No Yes No Yes No
monitoring)
Concrete surfaces and ground free of Yes No Yes No Yes No
any evidence of new leakage or spillage
Vent pipes secured and with proper Yes No Yes No Yes No
caps (Open vent: diesel /fuel oil;
pressurized vent: gasoline)
Electrical connections secured Yes No Yes No Yes No

Deficiencies Noted: Action Taken: Expected Date of Repair

Report all deficiencies to:

Certification: Inspection has been performed in a manner consistent with the requirements of Part
613.6:
Inspectors Name (Printed) Date:
Signature