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Afforda-R -"t Desia-ated Operator <br /> 800 524-9087 FAX 2u9 794-0112 I Monthly. section Checklist <br /> Y _ P <br /> FDesignated <br /> li Name: I ' FU e! (�P <br /> li Address: - R r Date: 2- 10 O <br /> i o n <br /> USTO erator IConductin the Ins ection: Code: q 5 3�obf,�+- -6owma_n <br /> national Code Council Certification#: 5 2y Q! 33 _ Expiration Date: 12 <br /> Signature: _________.. <br /> Phone:(Zp q ) g q U -D f D <br /> Item MONITORING PANEL/ALARM No,NA—Not A licable <br /> N NA <br /> Y <br /> 1 Monitorm stem is powered on and ui,proper op eratin mode. <br /> 2 Monitoringstem is not currentl showin analarms or warnings. X <br /> 3 Alarm history report/log for the previous month is available,and the <br /> Desi ated UST O erator. Attach a co o the alarm histo rformi available.) <br /> 4 Each alarm for the revious month has been responded-to appropriately. <br /> 5 Sensors'located in tank-to containment sumps have not alarmed in the past month. O <br /> 5a _ List all tank-top sumps inhere alarms occurred in the past month: X <br /> Note:Sumps where an alarm has occurred in the past month mart be inspected ranless a qualified service technician responded to,and <br /> Properly addressed,the cause of the alarm.Attach documentation verifying appropriate service to this report. <br /> I sum ins ection is required,record results in item 6,below. <br /> ,._y..r..:.;Z a.o>iF..Jy: ', ...,:: "c...�:,,. . .•-;:n,r _;: .w-.<....T Ha.+F^•.;,,r.,;WftM..:',z(Y15` <br /> UST SYSTEM INSPECTION <br /> 6 Tank-top containment sumps are free of water,debris,and hazardous substance. Sensors are to cat ed'properly. <br /> Note: Visual insDection o sum s is on re aired in sum where an alarm has occurred in the ast month or which there is no service record. <br /> Y N y <br /> N ' <br /> Y <br /> Sum Location: �( <br /> ;y, Sum Location: '? ( ;I I <br /> 1 Sum Location: X � Sum Location: G)I <br /> Sum Location: - <br /> r "s '-T Sum Location: Pia <br /> 7 S ill containment tructures are free of water debris,and hazardous substance. <br /> Y N NA N NA <br /> Y <br /> Tank 1-Contents: i GSF I Tank 3-Contents: <br /> Tank 2-Contents: <br /> 8Under-dis eraser containment areas are free of water,debris,,and hazardous substance. 7Sensors are located to erl . <br /> Y N NA N NA <br /> Y <br /> Dispenser 1/2 Dis eraser a/10 �( <br /> Dis enser 3/4 X D;­­11/12 <br /> Dis enser S/6 k <br /> 7/8 <br /> Dis enser 13/14 <br /> Dis enser X <br /> Dis enser <br /> PAPERWORK INSPECTION , .A• :':'� �.V..M`"E <br /> N NA DATE DONE <br /> Y <br /> 9 Monitorings stem certification has been com leted within ast 12 months. J r' p(o iU <br /> 10 Second containment tests have been com feted within the re uired timeframe. i< <br /> 11 S ill containment structure bucket testis was com feted within the ast ear. n ! <br /> 12 Tank ti tress testis was com feted within re uired timeframe. <br /> 13 Line ti tness testing was com feted within re uird timeframe, <br /> 14 Other required testis maintenance was completed within required timeframe. (List test/maintenance items beloly. <br /> Test/Maintenance: <br /> Test/Maintenance: <br />