SPCC Oil-Water Separator Assessment Form

Oil-Water Separator Name or ID:	Date:

Inspector Name (Signature)	Supervisor Name (Signature)

Measurements Made Through Access Cover*	Measurement Results (inches)
A. Distance from the rim of the access cover to the bottom of the oil-water separator:
B. Distance from the rim of the access cover to the top of the sludge:
C. Depth of accumulated sludge (A-B):

Question	Yes/No	Comment
Visible Observations through Access Cover
Is water present in the oil-water separator:	Yes No
Is the water level above the minimum water level?	Yes No
Is oil visible on the surface of the liquid?	Yes No
Is floating debris visible on the surface of the liquid?	Yes No

Was oil removed? Yes No	How was the oil disposed?
Was sludge removed? Yes No	How was the sludge disposed?
Do the floor drain sand traps need to be cleaned out? Yes No	Were the sand traps cleaned out? Yes No

For instructions, refer to Appendix D.2 in your SPCC Plan.

*	Measurement of the sludge level is not necessary if the height of the sludge relative to the height of the sludge baffle can be visually observed.

NDOT Form 115, August 17