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[tem <br />Designated underground Storage Tank (UST) Operator <br />Monthly Visual Inspection Checklist ' — <br />on #: `ALF 771 E P—hone: ja0 <br />MONITORING PANEL I AI.AR� HISTORY <br />Y=Yes.N—Nu,NA=NOt _ Licabi <br />N NA <br />Y <br />n mode. <br />1 Monitorin stem is veered on and in or ware. s. <br />2 hlomitorin s stem is not eurrentl sbowin an alarmsie <br />3 Alarm history reportlog for the previous month is available, and l; / 'lO to we <br />this armreviewed y Liable. <br />Desi at ed UST O tor. Attach a 10 <br />rn o the alarm his <br />4 Each alarm for the rsvious month has been ratted ro a ro tiatel . <br />5 Sensors located in tank -t containments have not alarmed in the ast month. <br />Sa List all tank -top sumps where alarna occurred in the past month: <br />r month mast w inspected unless a qualifiedsetvia technician ,�wpnderl to, and <br />)volt: Sumps ,vlur'e <+" alarm has' ° in the pas service !o this report the rause of fhe alarm_ Attach docunrenfatlon verPfvtng 4Pp�l <br />Pel Y � <br />1 sura insion is reauired. record resales in item 6. below. <br />UST syS KM INSPECTION are located properly - <br />6 Tank -top containment sumps are free of water, debris, <br />and hazardous substance_ Senso <br />Noce: Viriwf i etiarr ofssum x is aul v rc uirml in snn ,aJx rr an alarm !tm' occnrrr d in the r rwonth ar which fhrre F..; no service n <br />Y I N Iy <br />7 <br />1 - Contents: <br />2 - Contents: <br />8 <br />11 sipill <br />12 Tank <br />13 Line <br />14 Otho <br />Sump Location: <br />free of water, debris, and hazardous substaz <br />Y N NA <br />Tank 3 - <br />Tank 4 - <br />areas are free of water, debris, and haz <br />Y FN——NA <br />Dis ertser 9110 <br />3 / 9 ✓ Dis enser 11 / 12 <br />;r <br />.r516 3 <br />�r 718 <br />' Dis eraser 13 / 14 <br />VDis user 15 / 16 <br />PAPERWORK INSPECTION <br />ing system certification has been coon feted within Past 12 months_ <br />containment tests have been co leted within the required timefr, <br />niainMeal structure ucket testin was co feted within the Past e <br />OtWess teslin was cam feted within aired timeframe_ <br />hmess testis Was completed within required timeh-a=. timetram <br />__.: e,e . sr:.,olsr,a�ntenance was completed within re,- <br />YI N INA <br />are located r0 Crl <br />N l�fA <br />Y <br />Y N NA l DATE DONE <br />Page 1 of 2 November 2004 <br />