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JUN-9-2006 12:34 FROM:CIRCLE K 8584116 'M: 19512705121 P.5r11 <br /> Designated Underground Storage Tank (UST) Operator <br /> Monthly Visual Inspection Checklist <br /> Facili Name: Date: <br /> Facili Address: k�roe ,1t <br /> Cit Zi Code: C4 O <br /> _ Desi oared UST O rotor Conduct'n the Ins n: s' <br /> International Code Council Certific 2 -� -U Ex iraiton Date: / / <br /> signature. <br /> V—Yes,N—No,NA—Not A livable <br /> Item MONITORING PANEL/ALARM HISTORY Y I N NA <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 reportllog for the previous month is available,and has been reviewed by the <br /> Desi nated UST rator. Attach a copy of the alarm history reporillog to this form if 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 /> - List all tank-top sumps where alarms occurred in the pose month: <br /> Note:Sumps where an alarm hos occurred in the pasr month must be inspected unless a quallfred service technician rerporded ia,and <br /> pmperly addressed,the cause of the alarm.Attach documentation verifying appropriate service to this report. <br /> Yjump inspection is re aired,record mulls in item 6,below, <br /> asaaaa <br /> uN e . a <br /> UST SYSTEM INSPECTION <br /> ank-top conh nmentsumps are free of water,debris,and hazardous substance. Sensors are located properly. <br /> Nola:K a/ins tion su r is osiuired in sumps where an alarm has occurred in the post month for which there is rm service record. <br /> Y I N Y N r <br /> Sump Location: Sum Location: ` ,tr,=i�.` <br /> Sump Location: Sum Localion: <br /> Sum Location: Sump Location: tt ;�. 1 <br /> 7 Spill containment structures are free of water debris,and hazardous substance. <br /> Y NA Y N NA <br /> Tank I -Contents: Tank 3 -Contents: <br /> Tank 2 -Contents: Tank 4- Contents: <br /> 9 Under-dispenser containment areas are free of water debris,and hazardous substance. Sensors are located propeel . <br /> Y NA I I Y N I NA/ <br /> Dis enser 112 Lre9/10 r <br /> Dis enser3/4 er 11/12 <br /> is enser 5/6 er 13/14 <br /> Dis enser 7/8er 15/16 <br /> ev [ e k A T. wu• 6. <br /> PAPERWORK INSPECTION Y N NA DATE DONE <br /> 9 MoWi�tarine system certification has been completed within past 12 months. 3 <br /> 10 Secondary containment tests have been completed within the required timeframe. <br /> 11 Spill containment structure bucket testing was completed within the past year. <br /> 12 Tank tightness testing was completed within required timeframe. <br /> 13 Line ti tness testing was completed within required timeframe. <br /> 14 Other required testin /maintenance was completed within required timeframe, List test/ aintenonce items below <br /> Test/Maintenance: I. <br /> ftr <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> FACILITY EMPLOYEE TRAINING Y J NA <br /> 15 All facili ent to ees have received the required on-the-mob trainingwithin the past year. <br /> 1 AAll facilityem to ees hired within the Past 30 days have received the re uired on-the-bb 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 I of 2 September 2004 <br /> WHITE COPY=Market Manager YELLOW COPY=Slone Manager <br />