ROAD CHEMICAL STORAGE SUBSITE INSPECTION RECORD

Wisconsin Department of Transportation

DT1873 5/2006 Trans 277 Wis. Adm. Code

PRINT or use MS Word to complete this form.

1. Site Identification Number / 2. Site Label / 3. Inspection Date / 4. Inspector Name
5. Site Address - Use house number or emergency response number - Include ZIP Code
6. Compliance Contact Name / Area Code – Telephone Number
7. Basic Directions to Site Location
8. Material Stored at this Subsite - Check only one / 9. Note Facility Type and Description
Bulk road salt / Liquid magnesium chloride
Salt sand mixture / Dry magnesium chloride
Liquid calcium chloride / Ice ban
Dry calcium chloride / Various Liquids
Salt brine / Unknown
10. Pad and Apron at this Subsite
10.1 Solid material is stored on a concrete or asphalt pad - If the answer is “No”, go to 10.2 / Yes / No
Absent / Slight / Moderate / Severe
10.1.1 Defects: Cracks, holes, etc. in apron are:
Apron not visible
See maintenance manual guideline 30.10 A1A-D
10.1.2 Defects: Cracks, holes, etc. in pad are:
Pad not visible
See maintenance manual guideline 30.10 A1A-D
N/A / Yes / No
10.1.3 The pad under the stockpile is adequately raised, crowned or sloped
to direct water away from the material.
10.2 If present, the design and condition of the berm serving this subsite or the entire site contains runoff on the site’s surface.
10.3 If present, a catch basin or holding pond serves only this subsite or this subsite along with other subsites
11. If this Subsite is a Structure / Shed / Crib / Hi Arch / Dome / Other:
Repairs needed to / N/A / None / Minor / Major
11.1 The roof
11.2 The walls
11.3 The door(s)
12. If this Subsite is a Tank / Single / Multiple / Num
Repairs needed to / N/A / None / Minor / Major
12.1 The tank
12.2 The tank support structure
12.3 Tank fixtures
12.4 The spill containment device
13. If this Subsite is a Stockpile / N/A / Yes / No
13.1 The material is covered or open only at the working face
13.2 The covering material and seams, if any, are water tight
13.3 The cover is sufficiently secured with weights or tied down
14. Operating practices at this Subsite / N/A / None / Minor / Major
14.1 Material amount spilled on apron
(10’ ± around base of structure or stockpile)
14.2 Material amount spilled on grounds
(10’ to 100’ ± around base of structure or stockpile)
N/A / Yes / No
14.3 Door closed or face covered if subsite not actively engaged in material transfer
14.4 Access to stored material is effectively restricted
14.5 Monthly material inventory records are available for this subsite / Unknown

15. Inspector Notes

FORM DT1873 INSTRUCTIONS

* These instructions presume automated data entry into form DT1873 from MSSM.

1. & 2. Automated data entry. *

3. & 4. Manual data entry. Provide inspector’s name, along with an employer identifier, e.g. Region Name or ET

5. Automated data entry, provided the data is in the record. Data should include a “house” number. If it doesn’t, block 7 should describe how to find the site. Add the “house” number, if necessary.

6. Automated data entry *

7. This block is optional. It allows for noting any unique directions or other information the inspector should know. It is titled, “Basic Directions…”, but it can be used for any desired text.

8. Automated data entry. * One of the material types should be automatically marked. The inspector is to verify that the right material is checked. Errors should be noted and the record corrected when data is entered into MSSM. “Unknown” is used for empty or unknown material. Last season’s use of “various liquids” as a place holder will require a change to material type frequently.

9. This block is now used to provide descriptive information to assist in identifying the physical facility on the site corresponding to the information preprinted on the DT1873 for this subsite.

Manual data entry for the rest of the form

10. All of Section 11 deals only with solid material.

10.1.1 Stockpiles often do not have aprons as thought of for a shed. As product is removed from the stockpile, any paved area exposed is actually the pad. Mark as not visible.

10.1.2 The references given can also be found in the DOT pavement maintenance manual. A pad may not be visible in a locked shed or under a pile of material.

10.1.3 The references given can also be found in the DOT pavement maintenance manual.

10.2 Give close attention to entrances.

11. This block is used only if the subsite is a structure. Check the type of structure. Whether repairs needed are minor or major is determined according to the judgment of the inspector using criteria supplied by DOT. If the subsite is not a structure, all items are checked N/A.

12. This block is completed only if the subsite is a tank. Otherwise all items are checked N/A. Check if the subsite is a single or multiple tank. Whether repairs needed are minor or major is determined according to the judgment of the inspector using criteria supplied by DOT.

13. This block is completed only if the subsite is a stockpile or a crib. Otherwise all items are checked N/A. Whether repairs needed are minor or major is determined according to the judgment of the inspector using criteria supplied
by DOT.

14.1 & 2 Any of the stored material courser than dust is deemed material. Material leaked from the door or cracks in the walls requires something other than “None”.

14.4 A padlock on the shed or on the fence around the site is effective restriction.

14.5 This is determined by pre-inspection correspondence unless records are visible on site.

15 This is an area for the inspector to add notes to him/herself or to the owner. If more space is needed, the section will expand according to the amount of typed information.