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A.fforda-Te* Desicr 'ed Operator <br /> 800 524-9087 FAX 209 794-0112 Monthly Inspection Checklist <br /> Facili Name: Date: ?/ r-- <br /> Facili Address: /c—S. ! j Fti,•,/ �n 6 i <br /> Ci ;,G, f y Zi Code: q 5 3 Cv <br /> Desi nated UST One—+-t-_nadqucting the Inspection: ��t Piz I <br /> International Code Council Certification f-1 i i_z, JC Expiration Date: c? <br /> Signature: -/7� <br /> Y=Yes,N=No,NA=Not A licable <br /> Item MONITORING PANEL/ALARM InSTORY <br /> N NA <br /> Y <br /> 1 Monitorin s stem is owered on and in Proper operating• mode. <br /> 2 Monitoring stem is not current( showing any alarms or warnin s. <br /> 3 Alarm history report/log for the previous month is available,and has been reviewed by the <br /> Desi ated UST Operator. Attach a copy o the alarm history report/7oreportl7og to this form i available.) �( <br /> 4 Each alarm for the previous month has been responded to appropriately. <br /> 5 Sensors located in tank-top containment sumps have not alarmed in the past month. X <br /> Sa - List all tank-top sumps where alarms occurred inhe ast month: -t 1 <br /> v�A"Lr 1• ��l i IJ r7 t-�"I<.Yh lJ ,('�.�� l� i ':.)�•.Gv,. , .� .: ., C•?� r <br /> Note:Sumps where an alarm has occurred in the past month mrist be inspected unless a q ratified service technician responded to,and <br /> properly addressed,the cause of the alarm.Attach dontmenlation veri ing appropriate service to this report. <br /> t srtm ins ection is required.record results in item 6,below. <br /> UST SYSTEM INSPECTION <br /> 6 Tank-top containment sumps are free of water,debris,and hazardous substance. Sensors are located properly. <br /> Note:Visnal inspection o sum s is on7 re uired in sttm where an alarm has occ7ured in the post month or which there is no service record. <br /> Y N v� u Fy' J r <br /> a y N =r <br /> Sum Location. ,x <br /> Sum Location:,�� 'r+ <br /> Sum Location: Sump Location: 9 <br /> Sum Location t , <br /> 7 S ill containment structures are free of water,debris,and hazardous substance. t / <br /> Y N NA N NA <br /> Y <br /> Tank 1-Contents: e; Tank 3-Contents: �[ <br /> Tank 2-Contents: v 4 5 �G Tank 4-Contents: <br /> 8 Under-dispenser containment areas are free of water,debris,and hazardous substance. Sensors are located ro erl . <br /> Y N NA N NA <br /> Y <br /> D <br /> ispenser 1/2 Dis eraser 9/10 <br /> Dispenser 3/4 <br /> Dispenser 11/12 1K <br /> 5/6 Dispenser 13/14 <br /> is enser 7/8 Dispenser 15/16 — �EE <br /> . <br /> 'I I PAPErRK INSPECTION JJDAI <br /> E DONE <br /> 9 Monitoringsystem certification has been completed within ast 12 months. t <br /> 10 Second containment tests have been completed within the required timeframe.1 IS ill containment structure bucket testis was com leted within the ast ear. <br /> 12 Tank tightness testing was completed within re uired timeframe. <br /> 13 Line tiahtness testing was completed within required timeframe. <br /> 14 Other required testis maintenance was completed within required timeframe. List test/maintenance items below. <br /> TestlMaintenance: <br /> Test/Maintenance: <br />