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• • <br />Designated Underground Storage Tank (UST) Operator <br />Monthly Visual InTection CheckUist - <br />Name: <br />City:I Zip ;� <br />Msiguated U T Operalm (:o the 'on: Jahn EW <br />In ternfltiong Code C"otmcil Cc5•t cadou # SOOOM3 - UC tion Date; November 24 2011 <br />Si ire: Mon— { 916 ) 211-1373 <br />X ='Yen, N — No, NA = ]Vot AIPP W <br />M(? 1 G PANEL f AI.A 14I HISTORY Y N NA <br />�vmSm'i.'\2 `n.. ' st :a„3i, ':Yr Sy.• sw'NVJiAC!fn:-q� e' ) <br />1 monitoring sygem is powmed on and in pTpq o anode. <br />2 lulcnriturilag cm is not sbowinMyalaxans or <br />3 Alarm history reportllog fbr the prWous mouth is a�vsilWA% and has been xevaesry by the <br />Designatod UST or, Attach cn a the alarm h • re to this orm i nvrulahle.) <br />4 Each alarm for the rao�ntb has been to - <br />5 Sensors located in tank top cont nnEueA[t have not alarmed in t1�a �t m cmmttr <br />Sa List all —tank -top smps where alarms voc.•urred in the past mmn1h: <br />Note: �rnrps ti'%ere? mt nku-no hti6 0 in the post mcxeth ururt be fnrpe�'ed �nlerr a gnuyTtfied re�rvicsr 1 eciM+ici�r rerprmded tD, and <br />prop&rjy addnvlyA rhe emcee ethan ajarm ArAwh documm*ifiGn wn-6bW GPPYEPTIO14E Ww— to lb- rgkWL <br />lfmr is rated ra�7t3 A11+ Q bels'r,, <br />UST SYSTEM INSYEMON <br />6 Tank -top containment mmo are free of water, debris, and l azardous substanne_ Sensors arc located properly. <br />Nora: iTiaual ins coon rum s ;ran hsad in s W1t81� an dlRrnl ha -s Dacurrad in the ast monrh or which there is no service record. <br />Y 1�F Y N <br />Sum Locution: 91 Sum Locarrort_ 87 <br />SumLaeadion 89 j" Sum 1,o,Wtion: Diesel y� <br />s4mp Lac don: wµ ;a'; :sr, Sum Locution: , <br />Tank I — Contents, <br />Tank 2 — Contents: <br />8Lnder CC <br />bis w <br />112 <br />pi nser 3 14 <br />Di S/6 <br />Dispenmr 718 <br />V I N I. NA <br />91 1 <br />89 <br />Kat areas are free of water, deo <br />Y I -jq I NA <br />Tank 3 — Contents: <br />Tank 4 — Coatlents= <br />L and ba=dm s sot <br />DIVenwr 11 / 12 <br />Dispenser J3 114 <br />Dtgmmr 15 / 16 <br />9 mon has been com feted within pag 12 mombse <br />10 Seeoudary centainsncnt tests have been completed with- the remired tland ame- <br />11 S zil cnn%kMIMt sttt,cW (bFket) tesfiWvas witbWMOthe si <br />12 Tank " wet abed withinTR4A <br />13 Litre tifeted was Co withi n nited timefrnme_ <br />i4 Otbcr - maintenaum was completed within Fnufft4 timeframe_ (I <br />T st/114elatenance: Leak Lktecfion — <br />kYl N INA <br />87 <br />Kesel <br />Sensors aze loead property. <br />Y N I NA <br />R-MEMIM <br />.W� . Rff, <br />ns below <br />-AGILITY E1PIAYEE TRAINING Y <br />15 All pcft empigees have ro=ved the On-N—job traullng within the past year. <br />16 All facility employees hired widin the 30 have— the on4he b hainin <br />Note: Any answer of "N- shmM be elPlsincd is the "MmeAt WCtiau an the fOWWing Page, and w W require <br />follow-up nedom <br />page 1 of 2 November 2004 <br />Li2O 3S d PILLISE 817T066S-60Z EP:LO ITOZ/EZ/ZO <br />