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Afforda—Tr St Desii- rated Operator <br /> 800 524-9087 FAX X09 794-0112 Monthl}.Aspection Checklist <br /> Facility Name: Q Q J F rue ve Date: — a — <br /> FacilityAddress: jj2pt r J �-p <br /> Ct ZipCode: <br /> Desi ted UST O erator Con actin the Ins ection: L I-E N 1 VY\Y 7h0 <br /> International COPCguricil Certcation#: / Expiration Date: it Z/ 7— <br /> Signature: <br /> Si ture: Phone:( Llt! p!/ <br /> Y—Yes,N—No•NA—NotA licabie <br /> Item MONITORING PANEL/ALARM HISTORY N NA <br /> Y <br /> 1 Monitoring stem is po=red on and m ro er operating mode. <br /> 2 Monitoring stem is not currently showing any alarms or waraings. <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 hLLoty Leeor0og to this fiyr i available. <br /> 4 Each alarm for the previous month has been responded to appropriately. <br /> 5 Sensors located in tank-top containment sumps have not alarmed in the ast month. <br /> 5a List all tank-top sumps where alar occur occurred in the past Jqop 1h:I�/a yzS 4 7Attr� ftp <br /> Ch'e(tCpDf 1IdC ee _5;,o <br /> a ;TgrflSo� is if)11`4l cv �eJc bia ° <br /> Note:Sumps where an alarm hasocc,,rredinAepastmonthmusthe inspected unless a polifred service technician responded to,and <br /> properly addressed,the cause of the alarm.Atwh documentation verging appropriate service to this report. <br /> srrm Ins ection Is required.record remrhs in item 6,belmr. - <br /> :..,:r,._.. <br /> UST SYSTEM INSPECTION <br /> 6 Tank-top contain"arefreeof water,debris,and hazardous substance. Sensors are located properly. <br /> Note:Visual in uired in sum s where an alarm has ocnnred in the t month or which there is no service record.%NFaY N NY <br /> Sum Location: '�� Sum Location:Sum Location: Sum Location: <br /> Sum Location: Sumv Location: <br /> 7 Spill containment structures are free of water,debris and hazardous substance. <br /> Y N NA N NA <br /> Y <br /> Tank M <br /> s: r� Tank 3—Contents: <br /> Tank s: rn c., " b-r Tank 4—Contents: <br /> 8 Underontainment areas are free of water,debris,and hazardous substance. Sensors are located m erl . <br /> Y N NA N NA <br /> Y <br /> Dis Dis nser 9/10 <br /> Dis enDis nser 11/11 <br /> Dis nDispenser 13 114 <br /> Dispenser 7/8 1 Dispenser 15/16 <br /> ._:.J.n.Y1wy.}vx —4 ..I:9:.: '.Y•......vY.. ..,.f.}cv,`.'ry-N{. a'tii.V.�,u.3.4 in✓ IY,.M N.v fa..yrY Y tVl,.av:.. W ...e�.; ..-wn'.a WFY4\I10. <br /> PAPERWORK INSPECTION N NA DATE DONE <br /> Y <br /> 9 Monitorin stem certification has been completed within ast 12 months. <br /> 10 Second containment tests have been com feted within there uired timeframe. <br /> I 1 S ill containment structure(bucket testis was completed within the ast ear. — <br /> 12 Tank ti tress testis was----Wed <br /> within re iced timeframe. <br /> 13 Line ti tress testis was com feted within re uired timeframe. <br /> 14 Other re uired testis maintenance was completed within required timeframe. (List rest/maintenance items belrnv. <br /> Test/Maintenance: <br /> Test/Maintenance: <br />