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,I DesignatedUsldergrouttdGr�T UST) Operator <br /> Menthly Visusi inspection khst <br /> FaciliName: r % r/ ' �_` t• .t`, Dat : <br /> FaCilily Address: e: . <br /> Cit :i r .: -m ode' t. <br /> -Desi nate 10STbiteratorConductin theins eetiod: ,. ' <br /> nternationel o e Eo iirctl Certification 1! - E ion Date: r' /r 4,/ <br /> Si tore: _ r. c;:Fi✓t, <br /> "- Y-Yas.N-Na NA-.Net Applicable <br /> - '1N0PTT'OWMIS PANELI iSTORY Y N aA <br /> 1 Monitoring system is powered on and in proper operating mode. <br /> 2 - Monitoring s stem isnotcurrent) showin an alarms or warnin s. <br /> 3 Alarm history report/log for the previous month is available,and lies en reviewed by the <br /> Desi tcd'UST 0 orator. Atiach o co ,o the alarm hisroi•v re o o n to this form i ovailafrte. <br /> 4 Each alarm for the previous monthltasbeen res coded to a ro nb <br /> 9 Sensors located in Lank-top containment aum s have not alarmed in a imil month. <br /> 39 List alf tank-tap sumps where alarms occurred in the past moat .v1•7 <br /> Nole.Seeps M'/ICfr an alarm h",m m red in the past^,wall 1"Usf he in.Yperfe IDYY a Qua4liad serviee in:hllicraa respm*d m,and <br /> pmperJy addressed,fhr.rause n/ihr alw•m.Athwh Annmre.rfmhni sreW/firlg prime awvktwthiregnrt. <br /> l war Jinn is r rarordtrs'ulca in+load.balluu <br /> DST SYSTEM MSPECTll .- <br /> b ank-top cuntainmenrsumpd are free ofwalcr,debris,andltazardou ubsrancc. Sertsma arhxatedproperty. <br /> Nair:YI.Y4ai erpen a sure Da Is err) grrdia,Mn .There M nlownAar eirnrrpalt •16r tukirblhelr is an rCrvlce ra'cst. <br /> N is <br /> Sump Loca"Mon.•- _ br to": <br /> Sow Guatian: .J f' - ��t ." W:t�•�'. <br /> Sum Location: " Sewt Ion: .a <br /> 7 4pillcontairturictit urru^.mrec am f=Df watex debris.wilhazudauti. ataace <br /> . , y, ,.N. x4i Y N NA <br /> Tank 1 -Contents: Tank-3- anrents: <br /> Tank2-Contents: `40 �CI 14ck4- <br /> 8 Under—dispenser containment areas arc freeof water,debris and he rdous substance. Sensors are)seated proper V V. <br /> Y <br /> N. NA I Y N NA <br /> Dispenser)/2 - Dis ens 9110 ' <br /> Dispenser 3/4 1 Di.s ens 11112 <br /> Dis enser S/6 1 Di.r ens 13114 - <br /> Dts Denser 7/8 1 Dia tens 15116 <br /> s <br /> PAP IERWO"INMCT40S I xM-NAI ONE <br /> 9 Monitoring em certificationbesbemcomp <br /> ietedMaltin stF <br /> +0. cantaintneet sesss.ltave beenro ted within <br /> -H ill coats) JQUCrtae t fes a+as <br /> .-1.2 .T-ankighin s twingvastompleudAvItItin required ttatcfraate. <br /> 13 Une tightness testing was completed within r uired uweframe <br /> t 14 Other required t stip /maintenance was completed within re uired t' cfrenit. List rest/maintenance itnns below.) <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> Test/Maintenancr: <br /> c FAEFEITV£EMPLOVt—£TRAI Y ... N I NA <br /> l5 'Ail fa ' ' 10 es have received fie uired un-th tra" ititm the 1 r. •� <br /> iG A11 ' 'c s hit'ed-wdthtn the nam 30 4,v,hoveT"C4Necl. re - cdou-the-•t: . <br /> ,No : Aoy answer af."N"fhettld be eaptefned inMte cema 4d feeNen the 4a1019wlwg page,and will require <br /> 'Page 1 oft September 2004 <br /> 90 'd Wtl ZO : VO 6002-£0-d3S <br />