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Afforda-i t Desi ited Operator <br /> 800 524-9087 FAX 209 794-0112 Monthly Inspection Checklist <br /> Facili Name: / ,�„ / k Date: ) G <br /> Facili Address: <br /> /S—�i7� ✓ i:� i� t��/ <br /> Ci . lh Zi Code: <br /> Designated UST O erator Conductin the Inspection: <br /> In <br /> Code Council Certification#: S a Z/5 _ /3.T U <br /> Expiration Date: iL <br /> Si nature: <br /> Phone:( ) <br /> Item MONITORING PANEL/ALARM HISTORY Y-Yes _Ho NA_���A licA <br /> N NA <br /> Y <br /> I Monitoringsystem is powered on and in proper operating mode. <br /> 2 Monitor;- stem is not currentlyshowing analarms or warnings. <br /> 3 Alarm history report/log for the previous month is available,and has been reviewed by the <br /> Designated UST <br /> Q-erator. (Attach a co y o the alarm histo re ort/!o to this form i available.) <br /> 4 Each alarm for the revious month has been responded to a ro riatel . <br /> 5 Sensors located in tank-top containment sumps have not alarmed in the ast month. <br /> 5a _ List all tank-top sumps ivhere alarms occurred in the past month: �o l <br /> Note:Sumps where an alarm has occurred in the past month must be inspected nnless a qualified service technician responded to,and <br /> properly addressed,the cause of the alarm.Attach documentation verifying appropriate service to this report. <br /> /sumpIfstimp 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: Visrtal inspection o sum s is on re mired in sumps where an alarm has ocntrred in the st month or which there is no service record. <br /> Y N N <br /> Sum Location: A,6 Sum Location: <br /> Sum Location: � .f 4 ;' <br /> Sum Location: y. <br /> Sum Location: -Y Sum Location: �4:`. <br /> 7 S ill containment structures are free of water,debris,and hazardous substance. <br /> Y N NA N NA <br /> Y <br /> Tank 1-Contents: i'Z / / Tank 3-Contents: ,! <br /> Tank 2-Contents: /7 !/ <br /> 8 Under-dis enser containment areas are free of water,debris,and d hazardousnsubstance. Sensors are located ro erl . <br /> Y N NA N NA <br /> Y <br /> Dis enser 1/2 , / Dis enser 9/10 <br /> Dis enser 3/4 5— <br /> l'�� Dis enser 11/12 <br /> Dis enser 5/6 Dis enser 13/14 <br /> Dis enser 71 8 Z 2 Dis enser 15/16 <br /> PAPERWORK INSPECTION . <br /> N NA DATE DOON <br /> Y <br /> 9 Monitor'sS system certification has been completed within ast 12 months. <br /> 10 Seco dnry containment tests have been completed within the required timeframe. <br /> 11 S ill containment structure bucket testis was completed within the past ear. <br /> 12 Tank ti tness testing was completed within required timeframe. <br /> 13 Line ti tness testis was com leted within re fired timeframe. <br /> 14 Other required testis maintenance was com leted within required timeframe. (List test/maintenance items below. <br /> Test/Maintenance: <br /> Test/Maintenance: <br />