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FEB. 21. 2006 8:35AM G N0. 599 P. 2 <br /> Designated Underground Storage Tank (UST) Operator <br /> Monthly Visual Inspection Checklist <br /> Name: -t Lew f Date: <br /> Faeili Address: O O LA.)e.5+ rQ <br /> C' G ✓\ Zi Code: <br /> Desi ated UST erator Conductin the In ection: ( �c {�o v� <br /> International Code o it Ce cation*: 5 S 4 - U iration Date: / S / <br /> Si ature: Phone: ) ct .1- <br /> Y-Yes NNo NA=Not Applicable <br /> Item MONITORING PANEL/ALARM HISTORY X N NA <br /> l' Monitorings stem is owered on and in zo oto eratin mode. <br /> 2 J.Menitorin .s stem is not currentlyshow' an alarms oz warnings. <br /> 3 Alarm history report/log for the previous month is available,and has been reviewed by the v <br /> Desi ted UST Operator. (Attach a co of the alarm histo re ore o to this orm available. I <br /> 4 Each alarm for the-previous month has been responded to appropriately. <br /> .5 .sensors located in tank-to containment sum have not alarmed in the past month. 1/ <br /> 5a 'List all tank-top swaps where alarms occurred in the past month: <br /> Ndro:57rmps where an alarm has ocaared in the past month musrbe inspected undesaaqualifiedservtca rechnlctan responded.o,and <br /> .. proparly addressed the cause ofthe alarm.dlAtch dommentavon veryying appropriate sewtca to this report. <br /> Lwmins ecdo:ismqufrod,rccard results rn item 6 helow. <br /> UST SYSTEM INSPECTION i <br /> 6 ank top containment sumps are free of water,debris,and hazardous substance. Sensors are located properly. <br /> Note:Visual inspection afsumpy is only re urmd ar sums where an alarm has occurred in[fre ast month rwhich there isno service record <br /> Y <br /> Sum Lobation: <br /> Swan <br /> Location: N <br /> Loc, SSuumm LLooccaataiioonn:: <br /> i 'N •" <br /> Sim;v <br /> Sum .Location: <br /> 7 S W containment structures are free of water,debris aad hazardous substance. <br /> X N NA Y .N NA <br /> Tank I—Contents_ V A1, ✓ Tank 3—Contents: D I LI <br /> Tanit 2—Contents': V1 I I Tank 4—Contents: <br /> 8. Under-dis enser containment areas are'free of water,debris,and hazardous substance. Sensors are located zo erl - <br /> X N NA I Y I N I NA <br /> DUs ewer 112 mjell I V I Di enser 9110 <br /> Dis enser 3/4 ✓ Dispenser 11/12 <br /> D' enser 5/6 e Dis enser 13/14' <br /> Di enser 7/8 Dis ewar15/16 <br /> PAPER'WORKINSPECTION X N NA DATE DONE <br /> 1 9 Monitorintr s stem certification has been completed within past 12 months. <br /> 10 Seconcontainment tests have been completed within the required timeframe. <br /> 11 Spill containment structure cket testioA wascom leted within the past year. <br /> 12 T'ezila titress testingwas completed withix ze sired timeframe. <br /> 13 Lihe - mess Testing was completed within required timeframe. <br /> 14 1 Other required re maintenance was completed within required timeframe. gist test/maintenance itsms below. <br /> Test/Matnrenance: <br /> . Test/Marhtenance;. <br /> TestlMainrenance: <br /> FACILr1'Y EMPLOYEE TRAINING Y N NA <br /> 1T,TAHXn ' ,ern In ees have received the required on-the-'ob training within the pastYear. ' <br /> 16 1 Al facility em to ees hired with n the ast 30 days have received there aired on-the-job training.: <br /> Note: Any answer of"N"should be explained in the comment section on-the fol':nwing rage,and will require <br /> follow-up action. <br /> Page I oft <br />