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RECEIVED <br />OCT 1 1 2017 <br />MONTHLY FACILITY INSPECTION CHECKLIST (Attachment BfNV1ROhMENTALHEALTH <br />PERMIT/SERVICES <br />Instructions: This nspection rec rd will be completed every month. Place an X in the appropriate box <br />for each item. If aiiy response requires elaboration, do so in the Descriptions & Comments space <br />provided. Further lescniptions or comments should be attached on a separate sheet of paper if <br />necessary. <br />Yes No Descriptions & Comments <br />Tank surfaces show signs of leakage ❑ <br />Tanks are damaged, rusted or dei eriorated ❑ <br />Bolts, rivets, or seams are damaged ❑ <br />Tank supports are deteriorated or buckled ❑ ,El <br />Tank foundations I ave eroded oi settled ❑ 1� <br />Level gauges or al nns are inop rative ❑ El <br />Vents are obstruct d ❑ .121 <br />Valve seals or gasb ets are leaking ❑ ❑ <br />Pipelines or suppoi is are damag d or deteriorated ❑ ❑ <br />Buried pipelines are exposed ❑ Q <br />Loading/unloading area is damaged or deteriorated ❑ 0 <br />Connections are nc t capped orb ank-flanged ❑ EJ <br />Secondary containment is damaged or stained ❑ <br />Dike drainage val s are open ❑ [3 <br />Fencing, gates, or lighting is no functional ❑ ❑? A <br />Signature: Date: <br />f? j- <br />lYacy 'Truck and Aulo Stop <br />