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Designated Underground Stotage Tank(UST) Operator <br /> Monthly Visual Inspection Checklist <br /> Facili Name: {�L�G Date: <br /> FacilityAddress: p its twLiz--p <br /> Ci 77,,: c;2Zi Code: <br /> Desi ated UST Operator Con aing the Inspection: rvtr <br /> International Cod Cqim4jl Certification#: S'25701 <br /> 4r I Expiration Date:f 2 / 2$1 (J6 <br /> Si azure: Phone: Loa 6Go —YY 3 <br /> Y-Yea,N-No,NA Not Andleable <br /> Item MONITORING PANEL/ALARM HISTORY Y I N I NA <br /> RUM R!VW. <br /> Monitoring system is powered oo <br /> "., n and in proper operating mode. <br /> 2 Monitoring system is not currently showing any alarms orwarnings. <br /> 3 Alarm history report/log for the previous month is available,and has been reviewed by the <br /> Designated UST Operator. Attach a c9py o the alarm histo2 revonqog to thisform if available. <br /> 4 Each alarm for the previous month has been responded toro riatel . <br /> 5 Sensors located in tank-to containment sums have not alarmed tt,thepast month. <br /> Sa Llst ail tank-top sumps where alarms occurred in the past month: <br /> Note:Slanps where an alarm has occurred m the past maNh must be inspected unless a qual(fied servrce iechmcian rusparuk d ta.and <br /> property addressed, the cease of the alarm.Adach documemation verifying appropriate service to this reporr. <br /> ! su ins eaion!s re uired,retard rerulu to item 6,below. <br /> UST SYSTEM,:_:.. <br /> INSPECTION <br /> 6 Tank-top containment sumps are free of water,debris,and hazardous substance. Sensors are located properly. <br /> Noir:Visual is cwtv rMaquiredin sums where an alarm has occurred in thtaLsf monrh or which there is no service record <br /> Y I N `, Y N <br /> Sump Location: Sum Location: <br /> Sainp Location: t Ston Location: <br /> Sump Location: Sump Location: <br /> 7 Sol If containment structures are free ofwater,debris,and huA-d6us substance. <br /> Y N NAY N 'NA <br /> Tank I -Contents: Tank 3-Contents: <br /> Tank 2-Contents: Tank 4-Contents: <br /> 8 Under-dis unser containment areas are free of water,debris and hazardous substance. Sensors are located properly, <br /> Y 1,N I NA I I Y I N' NA <br /> Ms user 112 Dis eraser 9/10 <br /> Dispenser 3/4 Dra enter 11112 <br /> Dispenser 5/6 Dispenser 13/14 <br /> Dispenser 7/8Ais eraser 15/16 <br /> PAPERWORK111 11�111 .71 .. <br /> INSPECTION Y N NA DATE DONE <br /> 9 <br /> Monitoring system certification has been coni leted within past 12 months. - 17-0 if <br /> 10 Secondary containment tests have'been completed within the ra uircd timeframe. <br /> I I Spill containment structure bucket testing was completed within the past year. <br /> 12 Tank fi hmess tostmg was completed within required timeframe. <br /> 13 Line ti moss testis wascom feted within required timeframe. <br /> 14 Other uired test' maintenance was completed within required thueframe. List rest/maintenance items below.) <br /> TesdMaintenanco. <br /> Tesi/Maintenance: <br /> Test/Maintenance: <br /> FACILITY EMPLOYEE TRAININC Y N NA <br /> 15 1 All facili em to aes have received therequired on-the-job within the past ear. <br /> 6 All facilityem to ees hired within-die past 30 days have received the required on-the ob trainin <br /> Note: Any answer of"N^should be explained in the comment section on the following page,and will require <br /> follow-up action. <br /> Page I of 2 November 2004 <br /> 90/60 39Gd N0I103clSNI tlPQ L9b9E9ET99 LE :9T 900Z/80/E0 <br />