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N <br /> Cn <br /> U <br /> CD <br /> Designated Underground Storage Tank (UST)Operator <br /> (p Monthly Visual Inspection Checklist <br /> N Facility Name <br /> CD Facility Address: <br /> (D .City' J3 r' rV'u,'-, -F <br /> I-r <br /> 'a Designated UST O erator Condunln� Zip Code: <br /> fntemational Code CeunalC the lnspec000. /j{'s•- <br /> O <br /> 6 Si azure: �'� � Es nation Dale: /U <br /> (D Phone:f L <br /> OItems s-rr..N=Nn.NA=NmA wnle D <br /> .�-. MONITORING PANEL/ALARM HISTORY Y N NA <br /> p) ' Monitoring system Is owered on and in Droper operating mode. X D <br /> pj Monitoring s stem is nut curtently showin any alarms or warnin s. <br /> 3 Alam history rep, log for the previous month is available,and has been reviewed by the (n <br /> Desi.Hated UST On (or (.41fach o 7110 o(fhe olornr his/ory ie rorU/o g to this folm i a'vnj0hle) K M <br /> O 4 Each alarm Cor the rations month has been res onded to a ro riatel-. <br /> 7 <br /> Q > Sensors located in tank-.o con[ainment sum shave not alarmed in the past month, l' <br /> a oa - Lm aH rank-top nnnps xhere olarma occ,irred it,the paar monde <br /> m <br /> v S R'where rn rdu.m Iw........ .n rho ryn+vrrnndr Hr tri ingrecru/wrfeo a qwd fieds ,itce rachtacraw rvpnuAed lo.awl <br /> fi ¢nJou <br /> Gpuh oddn d f e /J- <br /> Mo.Perff&PW iropLimc <br /> i!. n mr rode d - nit ..6hol., 'f <br /> � al O <br /> UST SYSTEM A4 v <br /> N 6 Tank-lop containment sumps are free of water,debris,and It 'does su CTI <br /> kf- l}m/nu <br /> ....... ret onlir fired irnerm vn here 11:111,hmoroln rhe gbrp m <br /> m Y N -- <br /> s <br /> Lmr t I_ocalton: Sump hocalinn: .q <br /> U) . tem Lnealion: <br /> U) : .Sump Loc tort: <br /> - .Sum t L ocarina .$un+p Loaaliou_ - - <br /> O - '1 Sill containment structures are free of water,debns.and hazardous substance. Z <br /> +: <br /> Y N NA <br /> Tank I --Conlcnli: -� _ •�-E 6L <br /> i <br /> CD Tank3-C'va w, <br /> (D -,� <br /> r Tank2-(brnenr`: Tank 4-C'ontews <br /> C 5 Under-dispenser containment areas are free of water,debris,and hazardous substance. ITl <br /> 0 rn <br /> O � Y ti NA - - - <br /> O /hc airier 1/7 n Die tenser 9110 <br /> --- —I <br /> C i <br /> /111 CIAO'3/4 <br /> i X DLt macer 11/]> <br /> (p LLsnefr,cr 5!6 x Dis enser13/14 - Cn <br /> /)v encer7/g <br /> Dir unser 11 It, <br /> CD <br /> t1' PAPERWORK INSPECTION ---- [ILL <br /> N 9 Monitnrin r s stem certification has been com feted within asl I o n", '— r,I <br /> kilu- <br /> 0 IO second' containment tests hare been complded within the r yt rd limeframe_ I' �(,- <br /> W <br /> I I mill containment struttme_(buckcl)lesu was completed within[he1a ear 'w <br /> CL tank lightness ICsun>_ was wmPletad within req weed limeframe Z <br /> O' I i Line ukhmess testing a tt Icled within rcguiud timeframe` _ <br /> � ' <br /> U) 14 -LA it required ICSI II(JRran lenentc was u>nip{Icd within rCgWfed time frame i/ �( <br /> (A — ler//, Inteu,...e _ <br /> �. N __-- <br /> Q,; !cnt/MairNenaurc <br /> .�. (ACl11It F;v1110VkI TR tINIA(;� <br /> IS All facilit ern to ee hi lr;t cit cd uu <br /> r tA <br /> roqurrn ihr ohuaiuui,orllhin <br /> - ii. f Ihe1uisl veal <br /> 16 All facli em IoYccs hit ed wiihm the r,, l t0 days have¢err.-ed the retuned on-the-ob t" nm <br /> O pte: Any answer of"N"should be crplamrd to Iht t omtnrrll at rtion do the(ollowillg P»Ke.And NiII[e wire <br /> foflow-up action. <br /> I <br /> I <br /> N <br /> O <br /> � Paye 1 oft <br />