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FROM :B.Z.SERVICESTRTION MAINTWE FAX NO. :916 371 2540 <br />Opr. 22 2905 10:40AM P5 <br />Designated Underground:' Storage. Tank (UST) Operator <br />Monthly Visual Inspection Checklist <br />Facili Name: <br />- Date: <br />Facility Addross: i I It <br />Monitoring s stoat is not currently showing any alarms or warnings, <br />Ci ° <br />Zi Code; <br />[]esi sled UST Operator Conductin the Ins octioni <br />Each alarm for the previous month has been res ended to appropriately, <br />Intbrnational Coof Council Certii ation #i <br />Ex iration Date: f / <br />Signature; <br />Phone: <br />A - _ _ . -.. I CQl 41-1\V, 11JI- Out /JJVIMWUM <br />Item <br />1 <br />MONITORING PANEL / ALARM HISTORY Y N NA <br />Monitoring s stern is owored on aod' in jar6par operating mode. <br />2 <br />Monitoring s stoat is not currently showing any alarms or warnings, <br />3 <br />Alarm history reportllog for the previous month is available, and has been reviewed by the <br />Designated UST O orator. Attach a co o the alarm histo reporft to this or»r i availctltie.) <br />a <br />Each alarm for the previous month has been res ended to appropriately, <br />S <br />Sensors located in tank -top containment sumps have not alarmed in the past month, <br />Sa <br />- List all tanlrrtop ,rumps where alarms occurred:ln the past month: <br />Note: Sumps where an alarm has occurred In the past month must be Inspected unless a qunl{/iadservice technician responded to, and <br />properly addressed, the came gf the alarm. Attach documentallon verifying appropriate service to this report. <br />sum Ins cotton is re Hired, record results to Item 6, below. <br />$ '$YSTI;l1'I.IN PECTION <br />6 <br />Tank -to contairtmen atm s 46 fhe bf water, debris, and hazardous substance. Sensors are l — <br />p p located properly. <br />ore: Visual Iry eCtlon an s is. a required to sum whom an alarm has occurred in the Past tnonth or which there is no service record. <br />Y .N; <br />Y N <br />Swtt Localfon: ' � Sum Location: <br />Sum Location; Sunt .Location: <br />Suer Location: Sum Location: <br />7 <br />Spill cotltalnrricnt struotures are free: of wager, debris, and: 1i edpus' substance: <br />Y NNA .. Y N NA <br />Tank I — Contents: Tank 3 — Contents: <br />Tank 2 — Contents,` Tank 4 P Contents: <br />S <br />Under di cnsor containment aseas.are freeafiwatdr debris and hazardous substance. Sensors are located ro erl . <br />Y . N : NA Y I N NA' <br />Die attser 1/ 2 V Dispenser 9 / 10 <br />Dip enser 3 / 4 Dispenser 11112 <br />Dlsettser S r d Dispenser 13 / 14 <br />D sway 7 r 8' Dis eraser. 1 s' / 16 <br />PAPERWORK INSPECTION Y N. NA DATE BONE <br />9 Monitoring system certification-has:been com leted with n past i2 months. <br />10 Secon containment tests have been Goth let6d within the re aired timeframe. <br />1 S ill containment struct ro (bucket). tostinw4s corm feted within the past year, <br />12 Tank ti tness testing was completed within re Wired timeframe. . <br />13 Line tightness testing was completed within rcgairo timeframe, <br />r4: Other required testin maintenance was com l6ted within required timeframe. List test/mairr'endnce items below, <br />r .iar��.. ....,. <br />FACILITY EMPLOYEE TRAINING Y NM <br />15 All facili em to Qes have received the require on -the- ob trainln within the past year, <br />16 1 All facility emplbyees hired within the past 30 days have received the required on-the-job trainina. <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 1 of 2 <br />November 2004 <br />