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Affo rda-Te$t Desig.iated Operator <br /> 800 524-9087 FAX 209 794-0112 Monthly Inspection Checklist <br /> Facility Name: Date: ' /.=s I /per <br /> Facili Address: ''_ r ` —�f� <br /> 1 Ci : (,. * L Zi Code: <br /> Desi nated UST Operator Conducting the Ins ection: �„ / /a. /I, <br /> International Code Council Certification#: r; --fps; —Expiration Date: :' <br /> Signature: ^ <br /> Phone: <br /> Y=Yes,N=No,NA=No71 �,,ble <br /> Item MONITORING PANEL/ALARM HISTORY <br /> Y <br /> I Monitor;-- stem is owered on and in proper operating mode. <br /> 2 Monitoring stem is not currentl showin any alarms or warnings. <br /> 3 Alarm history report/log for the previous month is available,and has been reviewed by the <br /> Desi ated UST r%---ator. (Attach a co o the alarm histo re ort/lo to thisform i available.) <br /> 4 Each alarm for the revious month has been responded to appropriately. <br /> 5 Sensors located in tarik-top containment sumps have not alarmed in the past month. <br /> 5a - List all tank-top sumps where alarms,�bccurred in the past month:- A)I ne,., <br /> Note:Sumps where an alarm has occurred in the past month mast be inspected unless 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 srrm ins ection is required,record results in item 6,below. <br /> ..._ .. '. .. .. .. 4 -.J::ri f::iF.k7 ii.0."Mi�vr J. ....C.e.Ni '.'s:y;r...". ,.:_,....i.b' .'..•..:.._....> M M. <br /> UST SYSTEM INSPECTION <br /> 6 Tank-top containment sumps are free of water,debris,and hazardous substance. Sensors are located properly. <br /> Note:Visual inspection o sum s is onl re uired in sum where an alarm has ocnrn ed in--vast month or which there is no service record. <br /> Y N y N <br /> Y Y <br /> Sum Location: j W <br /> Sum Location: el',), <br /> Sum Location: ` <br /> Sum Location: F2 o 47 <br /> Sum Location: IJ? Sump Location: .0;1G y r�'�.✓ t °ti, <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: Tank 3—Contents: <br /> Tank 2—Contents: t�' Tank 4—Contents: , , > <br /> 8 Under-dis enser containment areas are free of water,debris,and hazardous substance. Sensors are located ro erl . <br /> Y N NA N NA <br /> Y <br /> Dis enser 1/2 <br /> Dis enser 3/4 is enser I1/12 <br /> Dis enser 5/6 Dis enser 13/14 <br /> Dis enser 7/8 Dis enser 15/16 <br /> PAPERWORK INSPECTION N NA DATE DONE <br /> Y <br /> 9 Monitoring system certification has been com feted within past 12 months. <br /> 10 Secondary containment tests have been com feted within the required timeframe. <br /> 11 S ill containment acture bucket testing was completed within the past year. <br /> 12 Tank ti mess testing was completed within required timeframe. <br /> 13 Line ti mess testin was completed within required timeframe. <br /> 14 Other re uired testin maintenance was com feted within re uired timeframe. List test/maintenance items belrntr. <br /> Test/Maintenance: <br /> Test/Maintenance: <br />