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FROM :B.Z.SEROICESTATION MAINTF*CE FAX NO. :91S 371 2540 r. 22 2005 10:41AM P7 <br />DesignatedUndergrourtdStorage Tank (UST) Operator <br />Mnnth1v Visual Insnection Checklist <br />Facili Name: . v tt <br />Date: 'i a <br />Facility Address; r <br />Monitoring s stern i oweRan and'in er o cretin mode. i <br />CiZip <br />Code: <br />Deiilgnated UST O eratgr Conductirig the+Inspection: <br />Alarmhistoryrepo log foe previous month is available, and has been reviewed by the v <br />Desi sled UST Operator. .4nacfa q, copy o' the alarm WiFtorp,re ortflyto this orm i available. <br />International Code Comuq Certs o tion #.rx <br />iration Date: <br />$i store: <br />Phone: 4 ;l , <br />I l 1 - z — r es. n - IYU. IN& - I'M AUDINCELPIC <br />item <br />MONiTUEtING PANSY. / ALARM HISTORY Y I N NA <br />I <br />Monitoring s stern i oweRan and'in er o cretin mode. i <br />2 <br />Manitorin stent i not ontl phowi» alarms or warnitis.3 <br />Alarmhistoryrepo log foe previous month is available, and has been reviewed by the v <br />Desi sled UST Operator. .4nacfa q, copy o' the alarm WiFtorp,re ortflyto this orm i available. <br />4 <br />Each alarm for the previous month has been responded o.appropriatoly. ,> <br />5 <br />Sensors located in tank -top cortta nment sunt shave�not alarmed in the Last month, <br />5a <br />List all tanlatbp sumps where alarms occurrsdJn the past month: <br />Note. Sumps where ah. alarm her occurred in thk past month must bs in speared unions a quadfled service lochnician responded to, and <br />properly addressed, the eats gfthe alarft ;!track dooumentaiion uarOMS appropriate service to #12 report, <br />a fns Action ld re tiered, recordresuits to Item 6, below. <br />'UAt SYSTEM INSPECTION <br />6 <br />Tank -top contalntti�nt stititps' are free of wetdr, debtis, and h$zardous substance. -Sensors are located properly. <br />ole; Visual Ida atom a .urns is:o ", rubes-in'rum s where an alarm has occurred In rhe past mond, or which there is no service record <br />Y'l, N Y N <br />Sum Location: ' r L -- $vmp Location; <br />Sum Location: Sum Locatlon; <br />Sum Location, 1s Sump Location; <br />7 <br />Spill cantaittr3l t sttu$tt m s ssrn firo®„af Water dobri� xt�d It z:u't3qu ; batiulaa; <br />. Y N NA <br />Y I N NA' <br />Tank I.—Contents.- r5SC, <br />3 --'Contents. <br />Tank 2— C'ontehts; t Tank 4 — Contents: <br />8 <br />Under -din cnser containment.areas. aro fhaa "bfwatc .:debri and hazardous substance. Sensors are located properly. <br />Y . N ': NA Y N NA <br />Dispenser 112 N Dispenser 9110 <br />Dis enser 3 / d 4,. Dispenser 11 / 12 <br />Dis eraser 5 / 6 V'.,, Dis ender 13 114 <br />Dispenser 718 %r Dispenser 1571 d <br />Note: Any answer of -N", should be elplatned In the comment section on the following page, and will require <br />folldw-tip action. <br />r. <br />page I of 2 <br />Novomber 2004 <br />