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JUL-12-2005 09:25 FROM:TRACY T' "K 8 AUTO S 1209E325307 T' 464013E3 P. 11 <br /> �ltsv�t�of <br /> Designated Undergrotnd Storage Tank(UST) Operator <br /> Monthly Vi,,ual Inspection Checklist <br /> Facili Name: -Date: (_ <br /> Facility Address: <br /> City: 11r Zip Code: <br /> Designated UST 0perator Conducting the Inspection: <br /> International Code until ifi tion#: St2 C Ex iration Date: / l V /O <br /> Si attue: Phone: 2 (( Z <br /> Ya Yes,N�Nq NA=Not A Geable <br /> Item MONITORING PANEL/ALARM HISTORY Y N NA <br /> 1 Monitoring stem is powered on and in proper )perat ng mode. <br /> 2 Monitoring system is not currently showing any alarms or warnings. <br /> 3 Alarm history report/log for the previous month is ava lable,and has been reviewed by the <br /> Designated UST Operator. Attach a copy o the alar» history report4og to this form i available. <br /> 4 Each alarm for the previous month has been to onded to appropriately. <br /> 5 Sensors located in tank-to containment su s 1 ave not alarmed in the past month. <br /> 5a _ List all tank-top sumps where alarms occur ed in t he past month: <br /> Note:Sunps where an alarm has octiared in thepastr umth en est be Inspected unless a qualf eiservice tecimician responded to,and <br /> property addressed,the causeaf the alarm.Attach don menta7i an verifying approprtam ser qm to rhis report. <br /> I sear :n aHan v r¢ vine(record resultr in Item 6, 'elmv. <br /> 11� <br /> UST SY,,-UM INSPECTION <br /> 6 seek top containtnent sumps are free of water,d.bris,t nd hazardous substance. Sensors are located properly. <br /> Note:Viral o is abed In where ea alarm fins occurred in the marsh whfch there is no service recorQ <br /> Y T Y N <br /> Su Location: (--1r Sum Location: <br /> Stun Loeah'on: I Sum Location: <br /> Stan Location: Sum Location: <br /> 7 ill containment structures are free of water,del ris and hazardous substance. <br /> Y - N NA Y NA <br /> Tank 1-Contents: Tank 3-Contents: <br /> _Tack 2-Contents: I Tank 4-Contents: <br /> 8 Under-dispense containment areas are free of wa or debris and hazardous substance. Sensors are located to 1 . <br /> TN NA Y NA <br /> Dispenser1/2 Dix enser 9/10 <br /> Dis nser3/4 enser 11/l2 <br /> Dispenser 5/6 Di enserl3/14 <br /> Dispenser 7/8 D' enser 15/16 <br /> PAPERWORK INSPECTION Y N NA DATE DONE <br /> _. <br /> _-9- -Monitoring stem certification has been completc d with inpast 12 months. <br /> 10 Secondsty containment tests have been completed within the required timeframe. <br /> 11 Spill containment structure(bucket)testing was co'npleu d within the past year. <br /> 12 Tank tightness testing was completed within re uired timaframe. <br /> 13 Line tightness testing was completed within requin d timeframe. <br /> 14 Otho required testis maintenance was completed within required timeframe. List test/maintermnce Items bel . <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> Test/hJcintenance: <br /> FACILITY EMPLC YEE TRAININGY7NNA <br /> 15 All facilityelnto ees have received the required of t-the-i 5b training within the past year. <br /> 16 All facili em to ees hired within the est 30 da s have tt eceived there uired on-the=ob training. <br /> Note: Any answer of"N"should be explained in the con ment section on the following page,and will require <br /> follow�up action. <br /> Pal e I of 2 September 2004 <br />