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1c:s1 F M:CIRCLE K 8584116 T.0:19512705121 <br /> P.2111 <br /> Designated Underground Storage Tank (UST) Operator <br /> Monthly Visual Inspection Checklist <br /> ,i;ili Name: mrt h t, Dale: <br /> :acili Address: u�lo <br /> Cit 2i Code: (� <br /> Desi nated UST orator Conductin the fns action: <br /> International Code Council Certification ti: Fx iration Date: 1. / / <br /> Si nature:_' Phone: <br /> AIIJS4�3rn 1), <br /> V=Yes,N=No,NA=Not A licable <br /> Item <br /> MONIT <br /> ALARM HISTORY y N NA <br /> ORING PANEL/ <br /> I Momtorm 'sA stem is powered on and in proper operating mode. <br /> 2 Monitorin s stem is not cutrentl showing any alarms or warnings. <br /> 3 Alarm history report/log for the previous month is available,and has been reviewed by the <br /> Desi ated UST O -rotor. Attach o co o the alarm histo re art/lo to this orm i available, <br /> 4 Each alarm for the revious month has been res onded to a roriatel . <br /> 5 Sensors located in tank-top containment sumps have not alarmed in the past month. <br /> a - List all tank-top sumps where alarms occurred in the past month: <br /> Nnte. Sumps where on alarm has acmrmd in the pact month must be inspected unless a qualified service technician responded to,and <br /> properly addressed,the muse of the alarm.Attach documentation verify/ng appropriate service to this repo". <br /> sum ins "ton is re aired,"aeon!resuhs In tram 6,blow. <br /> UST SYSTEM INSPECTION <br /> ank-top containment sumps are free of water,debris,and hazardous substance. Sensors are located properly. <br /> Note. Veraral impaction o sum is on re iced in sum when an alarm has occurred in the post month t0br which there is no service record. <br /> Y N Y N <br /> Sum Location: Sum Location: <br /> Sum Location: <br /> Sum Location: 4 <br /> SUMP Location: 77MSump/•"esti"": -,gF* <br /> 7 Split containment structures are free of water debris and hazardous substance. <br /> Y NA Y N NA <br /> Tank 1 —Contents: Tank 3 —Contents: <br /> Tank 2 —Contents: - Tank 4—Contents: <br /> 8 Under-0is enser containment areas are free of water,debris,and hazardous substance. Sensors are located properI <br /> YNA Y N N <br /> Dispenser 112 Dia Dispenser 9/10 <br /> Dia enser3/4 D' enser 9110 <br /> Dis rnser S/6 KtZ <br /> is enser 13114 <br /> Dis enser 718 Dis en.eer I s/16 <br /> ;. y.. . , .. <br /> PAPERWORK INSPECTION Y N NA DATE DONE <br /> 9 Monitorin s stem certification has been complete within past 12 months. <br /> 10 Seconds containment tests have been completed within therequired timeframe. 1-13 4 <br /> Il S ill containment structure bucket testi" was com leted within the past year. N <br /> 12 Tank ti htness testi" was completed within required timeframe. <br /> 13 Line ti htness testi" was cont Ieted within required timeframe. <br /> 14 Other re tired testi" maintenance was completed within required timeframe. List t/maintenance items below. <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> FACILITY EMPLOYEE TRAINING y ryp <br /> 15 All facilit em to ees have received the required on-the-job training within the past year. <br /> 16 All facilit em to ees hired within the ast 30 days have received the re uired on-the-'oh trainin . <br /> Note: Any answer of"N"should he explained in the comment section an the following page,and will require <br /> follow-up action. <br /> Page I of 2 September 2004 <br /> WHITE COPY=Markel Manager YELLOW COPY=Smwo Manager <br />