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p.12 <br />Designated Underground Storage Tank (BUST) Operator <br />Mondily Visual Inspection Checklist <br />Date: <br />Facilit Name: tt R I/vT iuA <br />Facilit Address: lel 6 G H., Zip Code. <br />Ci : <S ' .n Ii <br />Desi ated UST O for Canductin the Ins ection: Y� "tion ate: I2 1 I S <br />International Code Council Certification 4: $o?47g51 -� Pyne: o70 4 <br />t A licablc <br />Si attrre: No <br />HISTORY N NA <br />item <br />MONITORING PANEL /ALARM Y <br />I Monitorine systcm is powered on and in propLxo rating! — <br />mode -2 Monitorin tem is dl not currenshowm* analarms or warnln . �. <br />reviewed <br />3 Alarm lo <br />hisrY repoMg09 for the previous month is available, and � o this orm� i�auaifable. <br />Desi aced UST Operator. flttaclr a co o the alo 3to o reponate[ ✓ <br />4 Each alarms for the re v ous month hasee <br />Kn res rtded <br />5 Sensors located in tank -lo c(mlainment sump s have not alarms in the t month. <br />Sa _ List all tank -top sumps where atarnrs occurred in the past rnoRrh: <br />le ectserviee techreicirep nespondedlo, and <br />Note_ Bumper where app alarm has occvrrad to thl uronlh must I e ins cted ant=ore to this report. <br />Proper*addressed. the cause of thr ularm..dttach docrarpentatfon verifying aPProP>< <br />! spun i cation u uired record resuth; in item 6. below <br />UST SYSTEM INSPECTION ro erl <br />t containment sumps are free of water, debris, and hazardous substance. Sensors are located properly - <br />of <br />p Y- <br />6 <br />Tank -lop N <br />Nut-: p co Fns lion t SU it onh• rind iYsamr Nwbere em alarm has 0C)"Wree in The <br />I month for which thrre is nu srrrice rzc <br />X <br />� + Sum Location: <br />Sum Locution: (/rV Lr Sum Location: <br />SuLocation: I t Sum Location: <br />Sum Location: our substattc e- N NA <br />7 5 M containment structures are free of water' debris' and azard <br />h <br />Y N NA Y <br />Tank 3 - Contents. <br />Tank ] -Contents Tank 4 - Contents: <br />Tank 2 - Contents: C 1 Sensors are located o M - <br />8 Under-dis er cotttainrrtenl areas are frse of water, debris, and hazardous substance. N NA <br />Y N NA y <br />,-i D;s eraser 9 / 10 <br />Dis user 1 / 2 Dir eraser 11 l 12 <br />Dis er 3 /4 Dis eraser 13 / 14 <br />Dis riser 5 / 6 Dis er 1 S / 16 <br />Dispenser 7 / S � N NA DATE DONE <br />PAPERWORK IirISPEC"TIOIeE ,Y <br />-U <br />feted within past 12 months. - <br />9 Monitorin system certification has been timefirame. G r 7 - t� <br />10 Secon Containment tests have been completed within the aired <br />1 I S ill containment structure ucket testin was corn feted within the t car. ` — <br />12 Tank ti mess teslingwas Com leted within aired timeframe. L - <br />13 Line ti tress testis was core feted within uirctt timeframe_ tinseframe. tLisf test/maimetrance items below. <br />14 Other aired testis maintenance was cam leted within <br />requ <br />Test/Mainterrance: <br />w Test/Maintenance: November 204 <br />Page I of 2 <br />