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P.10 <br />Designated Underground Storage Tank (UST) Operator <br />Monthly Visual Inspection I'llChecklist =70 � <br />11 Date: - I <br />Facili Adaress: ra► c Lt t Dire: - <br />Cit S r a Httw.� <br />Desi ed UST O for Conductin theft) ection:117- <br />Riration pate: I2 / 1S 1international Code CouncilCertification##: Sc2�` % i to Phone: o <br />Si afore: Y = Yes N No. NA = Not A ticab' <br />1�1 NA <br />[tem MONITORING PANIEL I ALARM HIS Y <br />I MonitOriD is wercd on and in r o eratrn r►tode- <br />or warnings' <br />2 Monilorin s stem is not currentl show' an alarms reviewed the <br />3 A� history reportllog for the Prcviaus month is available, and � to this ormy availdbte. <br />Desi ted UST Operator. Attach a co of the added o aro ro riatel . <br />4 Earn alarm for the reviou, month has been <br />5 Sensors located in tante-to containments have not alarmed in the month. <br />past month: <br />5a List all tank -top sumps where alarms 0--cu-ed--cu-edin the <br />where art almnv has nect,rrext is <br />the past month _aW be inspected unless a q ualefred saves rectuuciax responded to. and <br />Nae: Sucep s r are soviet to rhis report. <br />YroperiY atrdrrsserC the cause of ncc alarm Artorh dacumentarlan verify nS QPP1Otu' <br />1 sn i action is Aired record results in iter+ 6. below_ <br />UST SYSTEM INSPECTION are located ro err <br />and hazardous substance_ Sensors P P Y- <br />6 Tactic -top cow inment sumps are free of water, debris. <br />a„ storm bus occrurmd in the r monrh for which there k nu s'ervire r <br />Note_ Yis„at ' eriurr o(s+un is anlr rr circa! iYsnm N N <br />Y <br />Page I of 2 <br />November 2004 <br />Sum Lacauon: LVE. Srtm Location: <br />Sum Location: <br />structures are free ofwater, debris, and hazardous substance- <br />N NA <br />7 <br />S ill containment <br />y N NA <br />y <br />^ Tank 3 — Ca»tenIs: <br />Tank 1 — [contests: /q <br />VQ /t't ✓ 3 ajjK 4 — Coatenrs: <br />Sensors are located r er <br />Tank 2 — Contests: <br />areas are free of water, debris, and hazardous substance_ <br />N NA <br />8 <br />Unde• riser containment <br />r-d <br />Y N NA <br />y <br />i/ Dis eraser 9 / 10 <br />Dis user I / 2 Da riser 11 / 12 <br />Dis nser 3 / 4 Dispenser 13 / 14 <br />Dis eraser 5 / 6 ✓ DisjyEer 15 / 16 <br />Das riser 7 / 8 <br />N NA DATE DON E <br />PAPEEtWORK iNSPEC•I'ION <br />Y <br />tem certification has been corn feted within l 32 months. <br />_ <br />9 <br />Monilori <br />tests have been co feted within the muired timeframe_ <br />10 <br />1 <br />Secondary containment <br />S ill containment structure ucket ”- "'v -was completed within the Past Year• <br />3 _e <br />I <br />12 <br />Tank ti tss testing was tom feted within aired timeframe_ <br />"-3 _U <br />13 <br />Line ti tress testin was completed within reauired <br />timeframe_ {LErt Jest/maintenance <br />items below_ <br />14 <br />Other required testinwmaintenance was comp feted within required <br />Page I of 2 <br />November 2004 <br />