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Designatea'Underground Storage Tank (US Tj�Operator <br /> Monthly Visual Inspection Checklist <br /> Facility Name: <br /> Date: <br /> Facilit Address: <br /> Zi Code: <br /> Designated UST Op erator Con duc[in the Ins ection: ;'-,'��,. - ic_. <br /> International Code Council Certification#: �? •!/ Ex iration <br /> Signature, Phone: . - F;M' <br /> FrinrY Yes,N=No,NA=Not Applicable <br /> y <br /> MONITORING PANEL/ALARM HISTORY Y N NA <br /> torin♦;system is owered on and in ro cr operating mode. <br /> orin s stem is no[cutrentl showin an alarms or warnings. <br /> history report/log for the previous month is available,and has been reviewed by the <br /> Hated UST O erator. Attach a co y ofthe alarm histm-v re ort/lo to this form tfavailable. <br /> larm for the revious month has been res onded to a ro riatel . <br /> rs located in tank-to containment sum s have not alarmed in the astmonth---•ist all tank-top sumps where alarms occurred is the-paYi month:ae:Stmrps where an alann Gasoccunedin thepaet month must be inspectedunless aguolif:edservice technician respondedto,and <br /> operly addressed the Cause r f the ahnar.Attach documentation relfbvg appropriate service to this report. <br /> sump inspecBon is regained,recordrendls in item 6.br7otr. <br /> UST SYSTEM INSPECTIONop containment sumps are free of water,debris, and hazardous substance. Sensors are located properly. <br /> Note: Visual inspection o('smnps is only re ed in stmtps rnc�rc un,dorm has occurred in the past month for which there is no service record. <br /> Y N <br /> Sum Location: _ Sunip Location: _ <br /> Surra Locatfde: Sump Location: <br /> Sum�Location:' Sum Loc lion.' <br /> 7 Spill containment structures are free of water,debris, and hazardous substance. <br /> Y N NA Y N NA <br /> Tank 1 —Contents. Tank 3—Contents: <br /> Tank 2— Contents: I I I / Tank 4—Contents: <br /> 8 Under-dispenser containment areas are free of water,debris,and hazardous substance. Sensors are locatedro erl . <br /> Y N NA Y N NA <br /> Dispenser 112 Dispenser 9110 <br /> Dis enser 3/4 Dispenser 11/12 <br /> DIS enser S/6 Dis tenser 73/14 <br /> Dimenser 7/8 Dis penser 15/16 <br /> PAPERWORK INSPECTION Y N NA DATE DONE <br /> 9 Monitorin s stem certification has been completed within past 12 months. <br /> 10 Seconda containment tests have been completed within the required timeframe. <br /> 11 S ill containment stmeture(bucket)testingwas completed within the past year. <br /> 12 Tank ti htness testin was com leted within re uired timeframe. <br /> 13 Line tightness testing was completed within required timeframe. <br /> 14 Other required testing/maintenance was completed within required timeframe. (List tesf/maintenance items below.) <br /> TestlMaintenance: <br /> Test/Maintenance- <br /> Test/Maintenance: <br /> FACILITY EMPLOYEE TRAINING YN NA <br /> 15 1 All facility employees have received the required on-the-job training within the past year. <br /> 16 1 All facility employees hired within the past 30 days have received the required on-the-job training. <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 September 2004 <br />