Document 8gbJ84OZZDebBx31v66RD9ya
Training Certificate
AMBER WHISNANT Date: 2021.09.22 18:38:19 -05'00' Digitally signed by AMBER WHISNANT
Facility Name WCHS Twelve Clans Unity Hospital
Agency Fac. ID 855
REPORT OF OPENING AND CLOSING CONFERENCES
Opening Conference
1. Give time of and list attendees of Opening Conference__ Paul McCarty Joseph Painter, ____
Michael Pomes, Eduardo Ortiz______________________________________________
_Date/Time: July 22, 2021 1:30 PM __________________________________________________
Circle Yes or No
2. Were UST Inspection Credentials presented?
Yes No
3. Was the statutory and regulatory purpose of the inspection explained?
4. Were areas of the facility being inspected noted?
5. Was a list of records being reviewed provided?
6. Was an opportunity given to claim confidential business information (CBI)?
7. Was the approximate duration of the inspection noted?
8. Were operators at the facility notified they have the opportunity to fix areas of concern identified during the inspection?
9. Was equipment used during the inspection noted?
Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Closing Conference
1. Give time of and list attendees of Closing Conference__Joe Heafner, Michael Pomes, Paul McCarty
Date/Time: August 26, 2021 1:00 ______________________________________________
Circle Yes or No
2. Was the purpose of the inspection restated?
Yes No
3. Was what happens with photos taken during the inspection explained?
Yes No
4. Were areas of concern and inspection observations discussed? Note: Compliance is the responsibility of the operators and any potential deficiencies or areas of concern are not the final determination of compliance.
Yes No
5. Was EPA's right to bring an enforcement action pending review explained? Yes No
6. Were any "fixed" deficiencies or areas of concern noted in the report?
Yes No
7. Were photos and copies of documents itemized on the report?
Yes No
8. Was the time frame for receiving the completed report given?
Yes No
9. Was the Small Business Resources Information Sheet provided?
Yes No
UST Inspection Report USTREPORT-001-R07 v3.3/April 2021
Page 2 of 21 Pages
Initial/Date:_JAH 8/25/21
1 UST Inspection Checklist
Agency Fac. ID 855
I. Ownership of Tank(s)
Tribal
II. Location of Tank(s) same as owner location (I.)
Owner Name:
WCHS Twelve Clans Unity Hospital
_____________________________________________________________
Street Address
225 Bluff Street
______________________________________________________________
County
Thurston
______________________________________________________________
City
State
Zip Code
Winnebago
NE
60871
______________________________________________________________
Phone Number
402-878-3601
______________________________________________________________
Owner Contact Person
Paul McCarty Paul.Mccarty@ihs.gov
______________________________________________________________
Facility Name or Company Site identifier, as applicable
WCHS Twelve Clans Unity Hospital
___________________________________________________________
Street Address or State Road, as applicable
225 Bluff Street
___________________________________________________________
County
Thurston
___________________________________________________________
City (nearest)
State
Zip Code
Winnebago
NE
60871
___________________________________________________________
Contact Person(s) at Facility
Phone Number
Paul McCarty
402-878-3601
___________________________________________________________
Latitude
Longitude
42.233397
-96.470561
___________________________________________________________
Do you own UST(s) at other UST Facilities Yes/No
If Yes, how many facilities_N/A_____________ How many USTs____ N/A __________________
Datum
WGS 84_____________________________________________________
ICIS/FERS Number:
Date entered:
___________________________________________________________
III. Notification (280.22)
Notification to implementing agency; name __WCHS Twelve Clans Unity Hospital_______________________[280.22(a)]
Agency Facility ID # _EPA-R7-USTFacID 855___; Agency notified? Y N Unknown NA [280.22(b)]
Has ownership changed in previous 30 days?
Y N Unknown NA [280.22(b)]
Have substances stored changed in the USTs?
Y N Unknown NA [280.22(b)]
Do newly stored substances include blends greater than E10 or B20? Y N Unknown NA [280.32(b)]
IV. Financial Responsibility (280.93)
Is documentation of financial responsibility available?
Y N Unknown NA
Does Wording Follows 40 CFR 280 Subpart B
Y N Unknown NA
Does FR mechanism cover cleanup of releases from USTs?
Y N Unknown NA
Does FR mechanism cover damage to property and third party liability caused by releases from USTs? Y N Unknown NA
Is amount of FR coverage adequate based on number of facilities?
Y N Unknown NA
$1,000,000 for less than 200 facilities
$2,000,000 for more than 200 facilities
Is amount of FR coverage adequate based on monthly throughput? $1,000,000 if through put greater than 100,000 gallons $50,000 if throughput less than 100,000 gallons
Y N Unknown NA
Does the FR mechanism list the covered facilities as registered by EPA on the Declaration Page? Y N Unknown NA
Does the FR mechanism provide first dollar coverage without self-insured retention? Specific Financial Mechanism used - check below:
State Fund _Nebraska Title 200____ Private Insurance: Insurer/Policy #______________ Guarantee Surety Bond Letter of Credit Self Insured
Local Government Not Required (Federal & State government, hazardous substance USTs)
Y N Unknown NA
UST Inspection Report USTREPORT-001-R07 v3.3/April 2021
Page 3 of 21 Pages
Initial/Date:_JAH 8/25/21
Facility Name WCHS Twelve Clans Unity Hospital
Agency Fac. ID 855
V. Operator Training (280.240) [List names, certificate numbers, expiration dates, trainer, and state]
A Operator(s): Paul McCarty
__________________________________________________________________________________________
B Operators(s): Paul McCarty
__________________________________________________________________________________________
C Operators(s): Paul McCarty________________________________________________________________
Does the owner have a list of designated operators currently trained at each facility?
Y N Unknown NA
Does the owner have evidence of operator training or retraining?
Y N Unknown NA
Were any of the designated UST Operators on duty during the inspection?
Y N Unknown NA
VI. Proximity of Groundwater Wells and Release History
Drinking water wells within 1,500 feet of the tank basin; is so note how many and list what types: Yes, Domestic water well northeast of facility,
Evidence of release or spills at facility Greater than 25 gallons (estimate)
Releases reported to implementing agency; if so, date(s) Release confirmed; when and how
[280.53]
Initial abatement measures and site characterization Free product removal
Soil or ground water contamination Corrective action plan submitted
Remediation ongoing
Remediation completed, no further action;date(s)
Unknown
VII. Tank Information (give numbers)
Tank 2
Tank presently in use
Yes
If not, date last used If empty, verify 1" or less left
(see Section IX.) (see Section IX.)
Most recent M/Y tank installed/upgraded (mm/dd/yr) 1/1/1999
Material of Construction: steel, impressed current, sacrificial anodes, composite, FRP,, internal lining, excavation liner single-walled (SW), double-walled (DW)
Capacity of Tank (gal) Substance Stored
E-15, E85 labeling correct? Are Compatibility Records available? [280.34(b)(3)] Is compatibility demonstrated? [280.32(b)(1) and (2)]
Yes No NA UNK Yes No NA UNK
Yes No NA UNK
Contained Submersible Turbine Pump (STP) Sumps Yes No NA UNK If yes, give installation date______1/1/1999___________
Is STP used for release detection? Yes No NA UNK
FRP DW
15,000 Diesel
NA NA
East Yes
Yes
West Yes
Yes
Is STP double-walled?
Yes No NA UNK
If Double-Walled (DW), Date of Last Monthly Integrity
Check of Annular Space? [280.35(a)(1)(i)] Note: only
No
No
applies to interstitial spaces under pressure or vacuum
or filled with brine.
UST Inspection Report USTREPORT-001-R07 v3.3/April 2021
Page 4 of 21 Pages
Initial/Date:_JAH 8/25/21
Facility Name WCHS Twelve Clans Unity Hospital
VII. Tank Information (give numbers)
Tank 2E West
Contained Submersible Turbine Pump (STP) Sumps
If DW, are the last 12 months of records available? Yes No NA UNK
NA
NA
If non-DW, Date of Last 3-year Containment Integrity Test? [280.35(a)(1)(ii)] Note: Triennial Sump Testing is required if sumps installed on or after April, 11, 2016.
Special Configuration Manifolded/Compartmentalized - Describe using tank numbers Field-Constructed/Airport Hydrant System FC or AHS
Pass 7/22/21
East STP sump
NA
Pass 7/22/ 2021
West STP sump
NA
VIII. Piping Information
Piping type
Pressurized
Suction
E. STP
X
W. STP
X
Agency Fac. ID 855
Piping Material: steel, copper, impressed current, sacrificial anodes, FRP, flexible nonmetallic single-walled (SW), double-walled (DW) Under Dispenser Containment (UDC) Yes No NA UNK If yes, give installation date___________________
Is UDC used for release detection? Yes No NA UNK
DW FRP DW FRP
NA
NA
NA
NA
Is UDC double-walled?
Yes No NA UNK
If DW, Date of Last Monthly Integrity Check of Annular
NA
NA
Space?[280.35(a)(1)(i)] Note: only applies to interstitial
spaces under pressure or vacuum or filled with brine.
If DW, are the last 12 months of records available? Yes No NA UNK
NA
NA
If non-DW, Date of Last 3-Year Containment Integrity
Test? [280.35(a)(1)(ii)] Note: Triennial Sump Testing is
NA
NA
required if sumps installed on or after April, 11, 2016.
Tank or piping properly designed and constructed according to a code of practice developed by a nationally recognized association or
independent testing laboratory [280.20(a), 280.20(b)] Y N Unknown NA
IX. Repairs
NA
Repairs are conducted according to a code of practice [280.33(a)] Y N Unknown NA
Metal piping sections/fittings that are damaged and have released product are replaced manufacturer's specifications. Non-corrodible pipes and fittings may be repaired in accordance with the manufacturer's specifications.
[280.33(c)] Y N Unknown NA
Repairs to secondary containment areas of tanks, piping, and containment sumps are tightness tested within 30 days of repair completion. All other repairs to tanks and piping are tightness tested within 30 days of repair completion (except when internal inspection conducted or
monthly monitoring is conducted) [280.33(d)] Y N Unknown NA
CP systems are tested/inspected within 6 months of repair of any cathodically protected UST system [280.33(e)]
Y N Unknown NA Internal linings repaired following standard code or practice [Citation needed] Y N Unknown NA
Repaired spill or overfill prevention equipment are tested or inspected within 30 days, as appropriate, in accordance with 280.35 to ensure
it is operating properly. [280.33(f)] Y N Unknown NA
Records of repairs are maintained [280.33(g)] Y N Unknown NA
UST Inspection Report USTREPORT-001-R07 v3.3/April 2021
Page 5 of 21 Pages
Initial/Date:_JAH 8/25/21
Facility Name WCHS Twelve Clans Unity Hospital
X. Temporary Closure NA CP is continued to be maintained [280.70(a)] Y N Unknown NA
Agency Fac. ID 855
Release detection is being performed and UST system contains > 1 inch of product [280.70(a)] Y N Unknown NA
Vent lines left open and functioning [280.70(b)] Y N Unknown NA
Lines, pumps, manways, and ancillary equipment capped and secured [280.70(b)] Y N Unknown NA XI. Corrosion Protection (CP)
Tank and piping components are constructed of or jacketed with non-corrodible materials, e.g., FRP, dielectric coatings,
plastic, etc. [280.20(a)(1), 280.20(a)(3), [280.20(b)(1)] Circle one or both: Tanks Pipes Y N Unknown NA
Implementing agency has determined that tank and piping construction and corrosion protection are designed to prevent releases in a manner
that is no less protective of human health and environment [280.20(a)(5), 280.20(b)(4)] Y N Unknown NA
Owners and operators have maintained records by corrosion expert to document that CP is not necessary [280.20(a)(4)(ii), 280.20(b)(3)(ii)]
Y N Unknown NA
Steel tank or piping coated with suitable dielectric material and cathodically protected [280.20(a)(2)(i), 280.20(b)(2)(i)]
Y N Unknown NA Field-installed CP system designed by a corrosion expert [280.20(a)(2)(ii), 280.20(b)(2)(ii) Y N Unknown NA
CP system tested and documentation maintained every three years or a time frame established by implementing agency [280.31(b)(1),
280.31(d)(2)] Y N Unknown NA
Criteria used to determine that CP is adequate was in accordance with a standard code of practice developed by a nationally recognized
association [280.31(b)(2)] Y N Unknown NA
CP system did not meet acceptable criteria at last test and action was taken by owner/operator to correct problem [280.31(b)(2)]
Y N Unknown NA Metal components in sumps NA
Tank
Tank numbers: 2E
Tank 2W
Are the metal components at the tank and dispenser isolated (e.g. booted),
cathodically protected or isolated? [280.20(b)(4)] Yes No NA UNK
Yes Yes
Notes:
East and West STP, Tank 2
STP piping isolated in contained East and West STP sumps
UST Inspection Report USTREPORT-001-R07 v3.3/April 2021
Page 6 of 21 Pages
Initial/Date:_JAH 8/25/21
Facility Name WCHS Twelve Clans Unity Hospital
XI. Corrosion Protection (CP) Tank numbers: Tank 2
Lining: [280.21(b)(1)]
NA
Periodic lining inspection requirements for tank met
NA
[280.21(b)(1)(ii)]
Yes No NA UNK
[10 years after installation, every five years thereafter]
Documentation that lining was installed [280.21 (b) (1) (i)] Yes No NA UNK NA
Shell integrity tested and passed?
Yes No NA UNK NA
Internal inspection test result - Pass or Fail
NA
If Fail, is tank still in service? [280.21(b)(1)(ii)]
Yes No NA UNK
NA
Sacrificial Anode:
NA
NA
CP system operated and maintained continuously. [280.31(a)] Yes No NA UNK NA
Last 3 yr test results show a voltage of at least -850mV? [280.31(b)(2)] Yes No NA
Dates of last two 3 yr test results available? [280.31(d)(2)]
Yes No
NA
List Dates:
Impressed Current: NA
NA Is the Rectifier on a dedicated power circuit? Yes No NA UNK CP system operated and maintained continuously. [280.31(a)] Yes No NA UNK NA
Last 3 yr test results show a voltage of at least -850mV or 100 mv shift [280.31(b)(2)] Yes No NA UNK NA
CP inspected and rectifier log maintained every 60 days to
ensure equipment is running properly. Last three test
NA
results available? [280.31(d)(1)] Yes No NA UNK
Dates of last two 3 yr test results available? [280.31(d)(2)]
Yes No
NA
List Dates:
Notes:
Agency Fac. ID 855
UST Inspection Report USTREPORT-001-R07 v3.3/April 2021
Page 7 of 21 Pages
Initial/Date:_JAH 8/25/21
Facility Name WCHS Twelve Clans Unity Hospital
Agency Fac. ID 855
XII. Spill and Overfill Protection [280.21(d)] Indicate any USTs filled by transfers < 25 gallons
For transfers greater than 25 gallons
Spill Prevention
Tank numbers: Tank 2
Device is present and functional? [280.20(c)(1)(i)] Yes No NA UNK Spill bucket free of water, debris, etc. Yes No NA UNK Double walled? Yes No NA UNK Note: only applies to interstitial spaces under pressure or vacuum or filled with brine.
Yes Yes
NA
If Yes, Last Monthly Check? [280.35(a)(1)(i)] List date: NA
If No, Date of Last Triennial Containment Integrity Test [280.35(a)(1)(ii)] List date:
7/27/ 2021
Overfill Prevention
Device is present and operational? [280.20(c)(1)(ii)] Yes No NA UNK Date of Last Triennial Inspection? [280.35(a)(2)]
Yes 7/27/21
Ball float valve riser present: [280.20(c)(1)(ii)(B) Yes No NA UNK Ball float valves are not suitable on suction systems, Yes with coaxial drop tubes, or pressurized deliveries. Ball float valve installed or replaced after October 13, 2015? [280.20(c)(3)] Yes No NA UNK NA Flapper valve Operational: [280.20(c)(1)(ii)(B)] Yes No NA UNK NA Automatic shutoff: Operational: [280.20(c)(1)(ii)(A)] Yes No NA UNK NA Automatic shutoff: Operational: [280.20(c)(1)(ii)(A)] Yes No NA UNK NA Alarms Operational: [ 280.20(c)(1)(ii)(B)] Yes No NA UNK Yes Visible and/or audible to jobber/driver? Yes No NA UNK Yes Location(s) of overfill alarm(s): South of Tank, North side of Building
Failure to take necessary precautions to prevent a spill or overfill during product delivery [280.30(a)] Y N Unknown NA
XIII. Tank and Pipe Release Detection
Release detection present [280.40(a)] Y N Unknown NA Note: Emergency Generator Tanks installed on or before 10/13/2015
must have release detection by 10/13/2018. Emergency Generator Tanks installed after 10/13/2015 but before 4/11/2016 must have release detection installed during installation. Emergency Generator Tanks installed after 4/11/2016 must have secondary containment and use interstitial monitoring.
Release detection system operating properly (i.e., system must be able to detect a release from any portion of the tank and piping that
routinely contains product) [(280.40(a)(1)] Y N Unknown NA
Release detection system meets the performance requirements at 280.43 or 280.44 [(280.40(a)(3)] Y N Unknown NA
Implementing agency has been notified of a suspected release as required, or when a release detection method or device alarms or fails a test
[(280.40(b)] Y N Unknown NA
Tanks and piping are monitored monthly for releases and records available (must have records for the two most recent consecutive months
and for 10 months of the last 12 months). [280.41(a), and 280.45(b)] Y N Unknown NA
Meets performance requirements for tank and line tightness test and maintains records.[280.43(c), 280.44(b), and 280.45(b)]
Y N Unknown NA
UST Inspection Report USTREPORT-001-R07 v3.3/April 2021
Page 8 of 21 Pages
Initial/Date:_JAH 8/25/21
Facility Name WCHS Twelve Clans Unity Hospital
XIII. Tank and Pipe Release Detection
Agency Fac. ID 855
Hazardous Substance UST Systems: NA
Release detection requirements are complied with for UST systems containing product. [(280.42)(b)]
Tanks and all piping systems equipped with secondary containment Pressurized piping w/ ALLD Monitored for a release every 30 days
Y N Unknown NA Y N Unknown NA
Y N Unknown NA
Pressurized Piping Set 1
TWO METHODS MUST BE SELECTED; ONE FROM EACH SET. E STP W. STP
Automatic Line Leak Detector (ALLD) installed (give date last tested/checked) Yes No NA UNK 4/8/2021
Annual function test of the operation of the leak detector within last 12 months [280.44(a)] Yes No NA UNK * In accordance with the manufacturer's requirements
NO
Yes
NA Yes 7/27/21
Does the owner/operator have ALLD function tests available for the last 3 years? Yes No NA UNK Operating so as to alert the operator to the presence of a leak (see 280.44(a) for description of ALLD) [280.44(a)] Yes No NA UNK Is the ALLD appropriate for the fuel stored in the UST? Yes No NA UNK Automatic Shut-off Device
(Electronic line leak detector (ELLD))
NA
Continuous Alarm System (sump sensor/double-walled
piping) Must meet leak threshold for large and small releases.
NA
Set 2
Tank numbers:
Annual Line Tightness Testing -- give date 4/8/2021 Is the last Line Tightness Test within the last 12 months? Yes No NA UNK Does the owner/operator have line tightness test reports available for the last 3 years? Yes No NA UNK Secondary Containment with Interstitial Monitoring
Yes No NA UNK Other (SIR, etc.)
Yes No NA UNK
ALM:IM
Suction Piping
Line Tightness Testing (required every 3 yr)
Yes No NA UNK
Yes No Yes NO Yes Tank 2E NA NA Yes
NA
Yes
Yes Yes Yes Yes Tank 2W Yes
NA Yes Yes
NA
Indicate date of most recent test
Secondary Containment with Interstitial Monitoring Yes No NA UNK
NA
NA
Other (SIR, etc.) Yes No NA UNK
NA
NA
No Leak Detection Required (must answer yes to all of the following questions):
Operates at less than atmospheric pressure Yes No NA UNK
NA
NA
Has only one check valve which is located directly under pump (dispenser) Yes No NA UNK NA NA
Slope of piping allows product to drain back into tank when suction released Yes No NA UNK
NA
NA
UST Inspection Report USTREPORT-001-R07 v3.3/April 2021
Page 9 of 21 Pages
Initial/Date:_JAH 8/25/21
Facility Name WCHS Twelve Clans Unity Hospital
XIII. Tank and Pipe Release Detection
Tank Numbers: Tank 2
Under Dispenser Containment (UDC)
List dates installed
NA
Note: Triennial Sump Testing required if sump installed
on or after April 11, 2016.
Are UDC Monitored? Yes No NA UNK NA
How are UDC Monitored? Visual or Electronic NA
Are records of inspections available? Yes No NA UNK NA
UDC Monitoring Notes: (Records of release: State the past 12 months monitoring records)
Agency Fac. ID 855
Tank Release Detection Summary
Mark Tank numbers with an "X"
Automatic Tank Gauging (ATG)
Automatic Line Monitoring (ALM)
Interstitial Monitoring (IM)
Statistical Inventory Reconciliation (SIR)
(refer to appropriate detailed RD form) Pages 13-18
X X X
Manual Tank Gauging (MTG)
XIV. Walkthrough Inspections [ 280.36 - Subpart C]
Owner and operators must conduct walkthrough inspections of the following:
Must have records for inspections performed every 30 days
Y N Unknown NA
Date of last 30-day Walkthrough Inspection___7/26/21_________________________
Spill Prevention Equipment - must be checked for damage, remove liquid or debris, and check
Y N Unknown NA
fill cap. [If deliveries occur at intervals greater than every 30 days, spill prevention equipment
can be checked at the time of delivery]
DW spill prevention equipment with interstitial monitoring - must check for leak in interstitial area. [Only applies to DW spill prevention equipment with vacuum, pressurized or brine-filled interstitial spaces]
Y N Unknown NA
Release detection equipment - must check to ensure operating with no alarms and review records of of release detection testing.
Y N Unknown NA
Do the 30-day walkthrough inspections follow a nationally recognized standard code or practice?
Y N Unknown NA
Are records of 30-day walkthrough inspections available for the two most recent consecutive months and for 10 of the last 12 months?
Y N Unknown NA
Must have records for inspections performed each year
Date of last Annual Walkthrough Inspection_6/16/2021___________
Containment sumps - must check for damage, leaks, remove liquid or debris.
Y N Unknown NA Y N Unknown NA
DW sumps with interstitial monitoring - must be checked for leak in interstitial area.
N Unknown
Hand-held release detection equipment - must check tank gauge sticks or groundwater bailer.
NA Y N Unknown
Does the annual walkthrough inspection follow a nationally recognizes standard code or practice? NA Y N Unknown
UST Inspection Report USTREPORT-001-R07 v3.3/April 2021
Page 10 of 21 Pages
NA
Initial/Date:_JAH 8/25/21
Facility Name WCHS Twelve Clans Hospital SITE DRAWING
DATE:
8/4/21
TIME ON SITE:
WEATHER: Partly cloudy, cool
0940
ENVIRONMENTALLY SENSITIVE AREA : Y N
If "Yes", please describe:
Agency Fac. ID 855
TIME OFF SITE: 1150
UST Inspection Report USTREPORT-001-R07 v3.3/April 2021
Page 11 of 21 Pages
Initial/Date:_JAH 8/25/21
Facility Name WCHS Twelve Clans Unity Hospital
Agency Fac. ID 855
NOTES:
ATG - TLS - 350 EAST STP: Sump Sensor on Bottom, Line Leak Detector Missing WEST STP: Sump Sensor on Bottom Spill Bucket - Free of debris and water at time of inspection
ATG SUMP- Tight, no water dry IS- Tight, No water Dry
UST Inspection Report USTREPORT-001-R07 v3.3/April 2021
Page 12 of 21 Pages
Initial/Date:_JAH 8/25/21
Facility Name WCHS Twelve Clans Unity Hospital
Automatic Tank Gauging (ATG) NA
Manufacturer, name and model number of system: Veeder-Root TLS-350
Third-party evaluators: Ken Wilcox and Associates
Agency Fac. ID 855
Unknown
NOTE: Most ATGs are not certified for use with used/waste oil tanks
ATG checking portion of tank that routinely contains product [280.40(a)(1)]
Device documentation is available at site (e.g., manufacturer's brochures, owners' manual, third-party certification)
Checked for presence of monitoring box and evidence that device is working.
Checked documentation that system installed, calibrated, & maintained according to manufacturer's instructions [280.40(a)(2)] ATG must be set for 0.2 gal/hr minimum
Monitoring (includes inventory) and testing records are available for the past 12 months
Year
Month
Tank #2
Tank #2
Tank #3
Tank #4
Tank #5
2021
January
Pass
2021
February
Pass
2021
March 29
Fail
2021
April 22
Fail
2021
May 10
Pass
2021
June 16
Pass
2021
July 8
Pass
2021
August 4
Pass
2020
September 22
Pass
2020
October 27
Pass
2020
November 23
Pass
2020
December 22
Pass
Yes No Yes No Yes No Yes No
Yes No
Tank #6
Non-passing results reported and resolved in accordance with implementing agency's directions. [280.40(b)]
NA Yes No
Annual Release Detection Operability
Test Date: __7/21/2021_______
1. Automatic tank gauge and other controllers: test alarm; verify system configuration; test battery backup.
2. Probes and sensors: inspect for residual buildup; ensure floats move freely; ensure shaft is not damaged; ensure accessible cables are free of kinks and breaks; test alarm operability and communication with controller.
3. Does the owner/operator have operability test records for the last three years?
Y N Unknown NA Y N Unknown NA
Y N Unknown NA
Pass 0.2 gal/hr on 8/4/21 Error- Bad Sensor, L2 Fuel Alarm Missing 0.2 gal/hr test for January 2021 and February 2021 Tank History shows Passing test for January and February 2021
UST Inspection Report USTREPORT-001-R07 v3.3/April 2021
Page 13 of 21 Pages
Initial/Date:_JAH 8/25/21
Facility Name WCHS Twelve Clans Unity Hospital Automatic Line Monitoring (ALM) NA
Manufacturer, name and model number of system: Veeder-Root PLLD
Third-party evaluators: Ken Wilcox Associates
Agency Fac. ID 855
Unknown
ALM checking portion of piping that routinely contains product [280.40(a)(1)]
Device documentation is available at site (e.g., manufacturer's brochures, owners' manual, third-party certification)
Checked for presence of monitoring box and evidence that device is working.
Checked documentation that system installed, calibrated, & maintained according to manufacturer's instructions [280.40(a)(2)] ALM must be set for 0.2 gal/hr minimum
Monitoring (includes inventory) and testing records are available for the past 12 months
Year
Month
Tank #2
2021
January 13
PASS
2021
February 18
PASS
2021
March 16
PASS
April
May
June
2021
July August September
No TEST
2020
October 24
PASS
2020
November 19 PAS
2020
December 16
PASS
Yes No Yes No Yes No Yes No
Yes No
Non-passing results reported and resolved in accordance with implementing agency's directions. [280.40(b)]
NA
Yes No
Annual Function Test
Test Date: _07/21/21___________
1. Automatic tank gauge and other controllers: test alarm; verify system configuration; Y N Unknown NA
test battery backup.
2. ALM units: ensure accessible cables are free of kinks and breaks; test alarm operability and communication with controller.
Y N Unknown NA
3. Does the owner/operator have function test records for the last three years?
Y N Unknown NA
PLLD stopped performing 0.2 gal/hr line test after 3/16/21
UST Inspection Report USTREPORT-001-R07 v3.3/April 2021
Page 14 of 21 Pages
Initial/Date:_JAH 8/25/21
Facility Name WCHS Twelve Clans Unity Hospital Interstitial Monitoring for: Piping / Tank(s) NA
Agency Fac. ID 855
Manufacturer and name of system: Veeder-Root
Sump Sensor IM
Date system installed: 1/1/1999
Materials used for secondary containment: FRP
Materials used for internal lining: FRP
Interstitial space is monitored (Circle one): automatically, continuously, or on a monthly basis.
If tank is of double-walled construction, what is material of construction?
FRP
If piping is of double-walled construction, what is material of construction? FRP
Documentation of monthly readings is available for last 12 months.
Year
Month
Tank Pipe
#1
#1
2021
January
2021
February
2021
March 29
P
P
2021
April 22
P
P
2021
May 10
P
P
2021
June 16
P
P
2021
July 1
P
P
2021
August
P
P
2020
September 22 P
P
2020
October 27
P
P
2020
November 23 P
P
2020
December 22
P
P
Yes No NA
Monitoring method is documented as capable of detecting a leak as small as .1 gal/hr with at least a 95% probability of detection and a probability of false alarm of no more than 5%.
Yes No NA
System is designed to detect release from any portion of UST system that routinely contains product.
Yes No NA
Secondary containment tight as to direct a release to the monitoring point and permit its detection [280.43(g)(2)] Yes No NA
Sensor is positioned correctly and operating in accordance with manufacturer's instructions [280.40(a)(2)]
Yes No NA
Non-passing results reported and resolved in accordance with implementing agency's directions. [280.40(b)]
Yes No NA
Annual Release Detection Operability
Test Date: ___ 7/27/21 _________
1. Vacuum pumps and pressure gauges to ensure proper communication with sensors Y N Unknown NA
and controller.
2. Sensors: ensure floats move freely; ensure accessible cables are free of kinks and breaks; test alarm operability and communication with controller.
Y N Unknown NA
3. Does the owner/operator have operability test records for the last three years?
No positive shut-off, Alarm should shut STP Down
Y N Unknown NA
UST Inspection Report USTREPORT-001-R07 v3.3/April 2021
Page 15 of 21 Pages
Initial/Date:_JAH 8/25/21
Facility Name WCHS Twelve Clans Unity Hospital Inventory Control [for Compliance Assistance Purposes only] NA
Agency Fac. ID 855
Inventory Control data input: ATG Manual tank gauging (stick)
Leak Check Calculation is performed each month to detect a release of 1.0 percent of flow-through plus 130 gallons. [280.43(a)]
Inventory volume measurements for regulated substance inputs, withdrawals, and the amount still remaining in the tank are recorded each operating day. [280.43(a)(1)]
The equipment used is capable of measuring the level of product over the full range of the tank's height to the nearest oneeighth of an inch. [280.43(a)(2)]
The regulated substance inputs are reconciled with delivery receipts by measurement of the tank inventory volume before and after delivery. [280.43(a)(3)] Deliveries are made through a drop tube that extends to within one foot of the tank bottom. [280.43(a)(4)]
Product dispensing is metered and recorded within the local standards for meter calibration or an accuracy of 6 cubic inches for every 5 gallons of product withdrawn. [280.43(a)(5)]
The measurement of any water level in the bottom of the tank is made to the nearest one-eighth of an inch at least once a month. [280.43(a)(6)]
Inventory Control Records are available for the past 12 months
Operator or owner has access to correct tank charts to convert inches to gallons.
Leak Check Calculation Results: P = PASS
Year
Month
F = FAIL N=None
Tank #1
Tank #2
Tank #3
Tank #4 Tank #5
January
February
March
April
May
June
July
August
September
October
November
December
Yes No Yes No
Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Tank #6
Non-passing results reported and resolved in accordance with implementing agency's directions. [280.40(b)] Notes:
NA
Yes No
UST Inspection Report USTREPORT-001-R07 v3.3/April 2021
Page 16 of 21 Pages
Initial/Date:_JAH 8/25/21
Facility Name WCHS Twelve Clans Unity Hospital Statistical Inventory Reconciliation (SIR) NA
Agency Fac. ID 855
Designer/Manufacturer and name of program: SIR Service Provider: Third-party evaluators:
SIR data input: ATG
* Manual tank gauging (stick) (Must follow the requirements for inventory control)
* Monthly water level readings recorded, drop tubes present, meters calibrated, and the dipstick is marked legibly and product levels can be measured to the nearest 1/8 inch
SIR documentation is available at site (e.g., designer's brochures, owners' manual)
Owner/Operator has documentation on file verifying method meets minimum performance standards of 0.20 gph with Pd 95% and Pfa of 5% for statistical inventory reconciliation (e.g., results sheets under EPA's "Standard Test Procedures for Evaluating Leak Detection Methods").
SIR results are available for the past 12 months
SIR Test Results: P = PASS Year
F = FAIL Month
INC = Inconclusive
N=None
Tank #1
Tank #2
Tank #3
Tank #4 Tank #5
January
Yes No Yes No Yes No Yes No
Tank #6
February
March
April
May
June
July
August
September
October
November
December
Non-passing results reported and resolved in accordance with implementing agency's directions. [280.40(b)] Receiving results within a time frame established by implementing agency [280.41(a) & 280.43(h)]
NA
Yes No Yes No
Annual Release Detection Operability 1. If ATG used for data input, refer to page 12 for annual testing requirements.
Test Date: ____________
2. If tank measuring stick used for data input: Hand-held sampling equipment (gauging Y N Unknown NA
sticks, etc.) to ensure proper operation.
3. Does the owner/operator have operability test records for the last three years?
Y N Unknown NA
UST Inspection Report USTREPORT-001-R07 v3.3/April 2021
Page 17 of 21 Pages
Initial/Date:_JAH 8/25/21
Facility Name WCHS Twelve Clans Unity Manual Tank Gauging (MTG) NA
Agency Fac. ID 855
Manual tank gauging may be used as the sole method of leak detection only for tanks of 1,000 gal or less, or in combination with tank tightness testing for tanks 2,000 gal. or less. * Manual tank gauging must be used in combination with tank tightness testing for tanks over 1,000 gal.
Records show liquid level measurements are taken at beginning and ending of period of at least 36 hours during which no liquid is added to or removed from the tank. [280.43(b)(1)]
Yes No
Level measurements based on aver. of two consecutive stick readings at both beginning and end of period.
Yes No
Monthly average of variation between beginning and end measurements is less than standard shown below for corresponding size and dimensions of tank and waiting time.
Yes No
Gauge stick is long enough to reach bottom of the tank. Ends of gauge stick are flat and not worn down. [280.43(b)(3)] Yes No
Gauge stick is marked legibly and product level can be determined to the nearest 1/8 inch [280.43(b)(3)]
Yes No
MTG is used as sole method of leak detection for tank.
Yes No
MTG is used in conjunction with tank tightness testing.
Yes No
Are all tanks for which MTG is used 2,000 gal or less in capacity? [280.43(b)(5)]
Yes No
Operator or owner has access to correct tank charts to convert inches to gallons.
Yes No
Check One:
Nominal Tank Capacity (gal)
Tank Dimensions
Monthly Standard (gal) Minimum Test Duration
( ) ( ) ( ) ( ) ( ) Year
Month JAN FEB MAR APR MAY JUN
Tank #1
550
551 - 1,000
1,000
1,000
1,001 - 2,000*
Tank #2
Tank #3
Tank #4
Tank #5
NA
NA
64" diam. X 73" length
48" diam. X 128" length
NA
Tank #6
Year
Month JUL
AUG
SEP
OCT
NOV
DEC
Tank #1
5
7
4
6
13 Tank
#2
Tank #3
36 hr 36 hr 44 hr 58 hr
Tank #4
Tank #5
Tank #6
Are monitoring records available for the last 12 month period? Performing proper recording and reconciliation activities [280.43(b)(4)] Non-passing results reported and resolved in accordance with implementing agency's directions. [280.40(b)]
NA
Yes No Yes No Yes No
Annual Release Detection Operability
Date: _____________
1. Hand-held sampling equipment (gauging sticks, etc.) to ensure proper operation.
Y N Unknown NA
2. Does the owner/operator have operability test records for the last three years?
Y N Unknown NA
UST Inspection Report USTREPORT-001-R07 v3.3/April 2021
Page 18 of 21 Pages
Initial/Date:_JAH 8/25/21
2 Underground Storage Tank (UST) Inspector's Observation Report
THE UNITED STATES ENVIRONMENTAL PROTECTION AGENCY (EPA) REGION 7 Tanks, Toxics, and Pesticides Branch LCRD/TTPB 11201 Renner BLVD Lenexa, Kansas 66219 913-551-7216
Facility Name:_WCHS Twelve Clans Unity Hospital Agency Fac. ID _EPA-R7-USTFacID-855__
No areas of concern or deficiencies were observed at the conclusion of this inspection.
The above named facility was inspected by a duly authorized representative of EPA Region 7, and the following are the inspector's
observations and/or recommended corrective action(s):
Deficiencies or Areas of Concern Identified:
Regulatory Citation
Description
280.40(a)(1)
PLLD stopped performing 0.2GPH line test After 3/16/21
280.40(a)(3)
Line Release detection system not meeting performance requirements
Actions Taken:
Field Citation; # ___
Additional information required
Inspection Deficiency Summary/Due date _
Notes:
Clean Spill Bucket Dry/Clean STP Sumps No positive shutoff. Alarm should shut down STPs
Name of Owner/Operator Representative:
See Original
____________________________________________________________ (Please print)
____________________________________________________________ (Signature)
Other Participants: ___________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Name of EPA Representative:
See Original
_______________________________________________________ (Please print)
_______________________________________________________ (Signature)
______________________________________________________ (Credential Number)
______________________________________________________ (Title)
Date of Inspection _________ Time __________ AM/PM
UST Inspection Report USTREPORT-001-R07 v3.3/April 2021
Page 19 of 21 Pages
Initial/Date:_JAH 8/25/21