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Designated Underground Storage Tank(LIST) Operator <br /> Monthly Visual Inspection Checklist <br /> Facil' Name: Date: - <br /> Facili Addresa: �e <br /> Ci Grp Zi Code: <br /> Desi UST error Coadu the on:Ton Fontana <br /> International code Council Certification#: I-UC .4-975Phone- on 09 95-4489 07 10 <br /> /2012S� atUxe; y�'�( N••No PU1•Not A, Ohre <br /> t2� <br /> MOMORM,PANEL/ALARM$LSTORY X N 1�TA <br /> M tom is eyed ami.and in mo& <br /> Monitozin s stemis not curt tial showin an alarm3 or w X <br /> Alarm WsW Y zepnNlQ for die.previous month is awailahle,and has beoa reviewed by the <br /> Desismated UST Operator. Attach a M of the alarm tory re oto this orm if available. <br /> 4 Each alarm for dto evious month has bees ded to D Yriatc) . <br /> 5 Sensors located iiu tank-top containment sum have not alarmed in the past month, <br /> Sa List all tank-top sumps where alarms oamorcd in the part month- <br /> ed service teCh►►tcimt neJporbdad td,trod <br /> Note:Sumps wheat an akvm hes aww?rd to the past mmA Horst be impededuroltss a Q�� <br /> prpp�fly ad& 4 the eawde of the aM m Amide dmwwnWi—wr(fft apprapriat�Se'vtce to thin report <br /> on is re tred rerexrtlLT.t)t ltem.6 below. <br /> IIST SYSTEIII IN3IPEMON <br /> 6 Tank-top containment sumps are free of water,debris,and hj=dous subst%p�� <br /> nsors are located properly. <br /> Now:Vflual i tan is a r tied to ,whens mi alarm her Qarvred inonth r whish theta is Y <br /> Sum Location: Sum ,LocationS`um Location: S LocationSum Location:. Sum Location <br /> 7 S ill containment structures am.free of-water debris ad hazardous substance. Y N NA <br /> Y NA <br /> Tank 3-Contents <br /> Tarok 1-Contents: . <br /> Tank 2-Contents: Tank 4-Consents <br /> g' Under-&s enser containment areas are freYof water�dc+bris and hazardous Sul.sauce. S4nso�is are lacat�d N A <br /> Dia eraser D' eraser 9 l l <br /> Dis ewers Dis eraser 11/12 -1- <br /> Dis eraser �¢ Di riser 13114 <br /> pis e><ser tfr q- Dis enr®r 15 116 <br /> PAPERWORK INSPECTION Y l!T NA DATE DONE <br /> 9 mons ''I'll 11 111111 <br /> tem oerij fi:: on has been feted within est 12 mouths. j <br /> 10 SeconjM containment tests have been completed,wig the uired timnefratne. <br /> 1! S contairanaut structure testis was feted within the past <br /> 12 Talc d tvess testi was leia�d within aired ti�eftarue. X <br /> 13 Line ' ttress testm was completed within timeframe. <br /> test/a►at»tenanc¢ <br /> 14 Other ro to maintenance was com feted within re uftzd timv$ame. ist ire>rts below: <br /> TOrtlMaintenance. <br /> �'ast/Irlafrttenmres: <br /> Tes�/,b�grntenance: <br /> FACILITY Em"YEE TRAINf!!TG ]V NA <br /> 15 All. em 1 ees have received the aired on the- b ' Vnihh the W <br /> 16 All facitimployees hired within the M 30&YShave received th®mqlured on-the-ob trainin <br /> Note: Any answer of"N"should be explained iu the eomtpent seerion on the following page,and Will require <br /> follow-ap action,. <br /> Page 1 of 2 November 2004 <br />