Underground Storage Tank Internal Inspection Form

Date of Inspection:

Facility Information

Address:

UPA Contact:

Inspector Information

Contractor:

Special Inspector:

Professional Engineer Number:

UST Information

Reason for Tank Entry

UST Primary Material

UST Construction

UST Contents

Results of Inspection

Was UST Lined?

_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

Additional Comments/Observations

Division of Water QualityUST Leak Prevention Unit

1001 I Street, Sacramento California 95812 (916) 319-9128 tanklining.notification@waterboards.ca.gov

10/13/17

10/13/17