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TUN-9-2006 12:32 FROM:CIRCLE K 8584116 TO:19512705121 P.3r11 <br /> Designated Underground Storage Tank (UST) Operator <br /> Monthly Visual Inspection Checklist <br /> Facili Name: Date: ir <br /> FacilityAddress: <br /> CZi Code: <br /> DnU Inspection: <br /> International Code Council Certification#: Ex tra ion ate: / / <br /> 04 <br /> Signature: Phone: <br /> Y=Ves,N=No, A=NntAppficable <br /> Item MONITORING PANEL/ALARM HISTORY Y N NA <br /> ,yrs., <br /> a' r Fyt. ...v a Yat, % v <br /> I Monitoring system is powered on and in proper operating mode. <br /> 2 Monitoring system is not currently showing any alarms or warnings. <br /> 3 Alarm history report/log for the previous month is available,and has been reviewed by the <br /> Designated UST Operator. Attach a co o the alarm histo re orf/(o to this form 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 past month. <br /> a - List all lank-top sumps where alarms occurred in the past month: <br /> Note:Sumps where an atom has occurred in the parr month must be Inspectedunless a qualified service mchnicion responded to,and <br /> properly addressed,the cause of the alarm.Attach documentutiun wrJying appropriate service to this report. <br /> l sum Inspection is required,record results in item 6.below <br /> LUST SYSTEM INSPECTION <br /> 4nk-top containment sumps are free of water,debris,and hazardous substance. Sensors are located properly. <br /> a <br /> Note: Pwal ins ion of"raps is only uired in=am where an alum has occurred in the past month for which there is no service record <br /> Y 11 N 11 RM I y IN <br /> Sum Loca(ion: fi-` i <br /> Sum Location: <br /> Sump Location: ,y Sump Location: <br /> Sump Location: ' A <br /> Sum Location: <br /> 7 Spill containment structures are free of water,debris,and hazardous substance. <br /> Y NA I NA <br /> Tank 1 -Contents: 14ant <br /> 3 7—Contents: <br /> Tank 2 - Contents: Tank 4- Contents: <br /> B Under-dispenser containment areas are free of water debris and hazardous substance. Sensors are located I ro erl . <br /> Y X NA I I Y N NA <br /> Dispenser 112Dls enser 9110 <br /> Dispenser][/4 is enser 11/12 <br /> Dis enser S/6 Dis enser]3/14 <br /> Dis enser]/8 Dis enser 15116 <br /> VAM, r.. <br /> PAPERWORK INSPECTION Y _ N NA DATE DONE <br /> 9 Monitoring system certification has been completed within past 12 months. It 90i; <br /> 10Seconds containment tests have been completed within the required timeframe. <br /> I t I Spill containment structure bucket testing was completed within the past ear. <br /> 12 Tank tightness testing was completed within required timeframe. <br /> 13 Line Lightness testing was completed within required timeframe. <br /> 14 Other required testing/maintenance was completed within required timeframe. (List fest/ma' Penance items below. <br /> TesdMaintenance: <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> FACILITY EMPLOYEE TRAINING Y 1,.N I NA <br /> 15 All facilit em to ees have received the required on-the=ob trainingwithin the past car. <br /> 16 All facilit em to ees hired within the Post 30 days have received the re uired on-the-job trainin . <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 I oft September 2004 <br /> WHITE COPY=Markel Manager YELLOW COPY=Stare Manager <br />