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JUN-7-CfMb 12:33 FROM:CIRCLE K _8564116 TO:19512705121 P,4r11 <br /> Designated Underground Storage Tank (UST) Operator <br /> Monthly Visual Inspection Checklist <br /> Facili Name: 1 . Date: <br /> Facilit Address: <br /> Ci : 0Zi Code: <br /> Desi noted US O erator Conductin the tion: ok" �,J <br /> International Code Council Corti on k: V1147o, -I-L,, Expiration Date: <br /> Si azure: Phone: c` h_ p <br /> Y=Yes,N=No,NA=NotA H ble <br /> Item STORY Y NA <br /> ITORINC PANEL/ALARM R <br /> I Monitorin s stem is owered on and in ro er o eratin mode. <br /> 2 Monitorin s stem isnot cutrentl showin an alarms or warmth s. <br /> 3 Alarm history repoNlog for the previous month is available,and has been reviewed by the <br /> Desi hated UST erator. Attach a co a fhe alarm histo re ort/lo to this <br /> 4 orm i avaEach alarm for the revious ilable. <br /> month has been res onded to a ro riatel . <br /> 5 Sensors located intank-to containment sum shave not alarmed in the ast month. <br /> List a!f tank-top sumps where alarm's occurred in the past month: <br /> Note.Sumps where an alarm has occurred to the part month must be inspected unless a quail led service technician responded to,and <br /> properly addressed,the cause of the a/amt.Attach documentation verifying appropriate service to this report. <br /> / sum "erttection is neuired,record nes'dts in item 6,below, <br /> UST SYSTEM INSPECTION ' <br /> 4ank-top containment sumps are free of water,debris,and hazardous substance. Sensors are located properly. <br /> Note: Y'sual ins etlan o sum is ant re uired in swnptr where an a/arm ha:occurred in theart month or which there is no service record. <br /> Y N .i11 y N fn <br /> Sum Location: t' .,�. Sum Location::.`° <br /> Sum Location: `.x <br /> c Sum Location: it;r"Y <br /> Sum Location: u Sum Location: E <br /> 7 Spill containment structures are free of water,debris and hazardous substance. <br /> V N NA Y N NA <br /> Tank 1 —Contents: Tank 3 —Contents: <br /> Tank 2—Contents: Tank 4 —Contents: <br /> 8 Under-dis enser containment areas are free of water debris,and hazardous substance. Sensors are locatedproperty. <br /> Y N NA Y N N <br /> Du enserl/I Dispenser 9/10 <br /> Dis enser 3/4 Dispenser 11/12 <br /> Dis enser S/6 is enser 13/14 <br /> Dis en ser 7/8 Dis enser 15/16 <br /> PAPERWORK INSPECTION Y N NA DATE DONE <br /> 9 Monitor <br /> system certification has been completed within past 12 months. <br /> LA11C Int- <br /> 10 Seconds containment tests have been completed within the required timeframe. <br /> 11 Spill containment structure bucket testingwas completed within the past ear. <br /> I2Tank ti htness testingwas completed within required timeframe. <br /> 13 Line ti htness testing was com leled within required timeframe. <br /> 14 Other required testin /maintenance was completed within required timeframe. (List t t1m.0inicnance items below. <br /> W16A11facilityern2loyeeshircd <br /> /Maintenance: <br /> Eemninveeshav,,r <br /> ce: <br /> ce. <br /> FACILITY EMPLOYEE TRAINING V N NA <br /> eceived the re uired on-the-'ob trainingwithin the past year, / <br /> within the.12ast 30 days have received the required on-[he-ob train in . <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 of 2 September 2004 <br /> WHITE COPY=Market Manager YELL OW COPY=S"we Manager <br />