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Designated Underground Storage Tank (UST} Operator <br />Monthly Visual Inspection Checklist <br />Facility Name- Chevron # <br />Date: - ti <br />Facili address: <br />City: L <br />Zip code. <br />_Pe!izateMT Operator Conducting the Ins ection: Edward Dahlgren <br />Intemational code Council crti ati # ° 5980-Uc <br />Expiration Date: 09/28/2012 <br />Si tune: <br />pltpne: (915 y 271 2363 <br />Y = YM N = No, NA = Not A lic2ta <br />Item -NION11 ORI1G PANEL l A1LA,It M HISTORY Y Ni 'tiA <br />1 Monitoring system is powered on and in proper operating mode,11, <br />2 <br />Monitoring s stem is not currently sh4 an alarms ar vvarnitl s. <br />3 Alarm history report/log for the previous month is available, and has been reviewed by the <br />Designated UST Operator. Attach a copy o the alarm hisropy re ort/lo to this orm i available. <br />4 F-46 alarm for the previous month has been res ended to a ro riatel . <br />5 Sensors located in tank -top containment sum s bare nut alarmed in the est rnpnth, <br />5a List all tank -top sumps where alarms occurred in the pea.vt month: <br />Note: Sumps where an alarm has occurred in rhe past month must be inspected unless a goal#led service technician, responded to, and <br />pmpsriv addresse . thL-,-a W- of the alarm. Attach dpCifn7lt?ndaliDYr Vcr ing appropr-iafr. servicer iu this report. <br />1 sump in.s eciicn is re iT tQf Neord rpm hs 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 />NOtex._ <br />visualins Coon 0 sum s is on7 r ui rsd i» awn S whsra an alarm has ocean ed at the asd month Cir }which them i5 n0 service YPCDrd <br />Y N Y N <br />,Sum Location: 87#I Siam Location: 91 <br />SUMLaeation: 87#2 Sum Location: Diesel <br />Sum Location: 89 3ump Location: <br />7 S ill containment structures are free of water, debris, and ha2ardous substance. <br />Y N NA 'Y N N A <br />Tank i -Contents: ,47#1 Tank 3 - Contents; 89 o 91 <br />Tank 2 -Contents: 87#2 or 89 Tank 4 - Contents: 91 or ieasel <br />8 Under- ispenser containment areas are free of water, debris, and hazardous suhtita.nrea. <br />NA <br />112 <br />314 <br />516 <br />718 <br />9110 <br />PAPERWORK INSPECTION <br />9 Moniwrin s stern certification has been, completed within past 12 m <br />10 5econ containment tests have been com feted witbin the r tlireC <br />11 S ill containment structure bucket testingwas completed within, the <br />12 Tank ti mess testingy4ra8 comvleted within re aired timeframe <br />13 Line ti tness testingwas completed within required timeframe. <br />14 Other required testin rrtaintenance was corn feted within re uiri d tin <br />7 PW Mainlenanoe: LLD testing was coin ]cted within the re utrt <br />3"ertiMaintenance: <br />7 estlMaintenance,• <br />11112 <br />13114 <br />15116_ <br />17118 <br />19;2(1 <br />V"Lq_JL11 r tiNI LOYEE TRAINING <br />15 All facility a �Iohave received the required on-thejob trainin within the est ear_16 All facilit emhired vvithin the ast 30 days have received the required on-the-job train <br />Note: Any answer of "N" should he explained in the ca <br />follow-up action. mirtent section On the following page, and <br />Page 1 oft <br />NA <br />DONX <br />items <br />Y I N INA <br />November 2004 <br />5T/Zo lovd bTLTISC) BtTO669-60Z t16:L0 ITOZ/EZ/ZO <br />