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Designated Underground Storage Tank (UST) Operator <br /> Monthly Visual Inspection Checklist <br /> Facility Name: — - ` `1 ) < <_ Date: _- <br /> acility Address: C L r' I) 7 <br /> Ci - - - j Zip Code: <br /> Designated UST Operator Conducting the on: Lon Freshour <br /> International Code Council Certification#: 5220353-UC Expiration Date:-laM6A)1'r <br /> Signature: Phonc: (916)826-1576 <br /> Item MONITORING PANELI ALARM HI&MRY Y N NA <br /> 1 monitoring system is p2wered on and in proper operating mode <br /> 2 monitoring em is not mirrently showing alums or warnings <br /> 3 Alarm history report/log for the previous month is available,and has been reviewed by the Designated US"r Operator. y <br /> Attach a copy o the alarm history report/log to thin orm if available <br /> 4 Each alum for the cvious month has been responded to to . L_. (o o �1 I �"r r' a ;i t Z C)-10 �F <br /> 5 Senors located in the tark- containment sum have not alarmed in the month <br /> 5a List all tank-fop sumps where alarms occurred in the past month: <br /> Note:Sumps where an alarm has occurred in the past month must be inspected unless a qualified sefvice technician responded to,and <br /> properly addressed,the cause of the alarm. Attach documentation venfying appropriate service to this report. <br /> Ifsump inspection is required,record results in item 6,below. <br /> UST SYSTEM INSPECTION <br /> 6 Tank-top containment sumps are free of water,debris,and hazardous stbstanlce. Sensors are properly located <br /> Note Visual inspedJon o7777 <br /> avrod m the t month for which there is no service record <br /> Sum Location: Sum Location: <br /> Sum Location: Sump Location: <br /> Sump Location: Sump Location: <br /> 7Spill containment stixWres are free of water,debris,and hazardous substance. <br /> Y N NA Y N NA <br /> Tank 1 -Contents U N I-- Tank 3-Contents r,: <br /> Tank 2-Contends V3 Tank 4-Conterds <br /> d UDC areas are free of water,debris,and hazardous substance. Sensors are pmperly located <br /> Y N NA I Y N NA <br /> Dispenser 1/2 Dispenser 9/10 N/1 <br /> Di nser 3/4 Dispenser 11/12 / <br /> Dispenser 5/6 Dispenser 12/13 N A <br /> riser 7/8 <br /> Dispenser 14/15 / <br /> PAPERWO INSPECTION Y N NA DATE DONE <br /> 9 Moreton system certification has been within the mst 12 months. <br /> 10 Containment tests have been stet within the rwored timeframe. ti�G <br /> 11 'II containment structure et testing was compleW within the past year. - <br /> 12 Tank tightness testing was completed within required timeframe. f1 <br /> 13 Line lightness testiwas cornpleW with reWred ti <br /> 14 Other reWrad testi maintenance was oornpleted within mWired bmetrame. List test/maintenance items below <br /> Test/Maintenance: �/-Cc <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> FACILITY EMPLOYEE TRAINING Y N w <br /> 15 All facility have received the required on- ob training within the past yox. y <br /> 16 All facility hired within the past 30 have received the required on- ob train <br /> Note:Any answer of"N"should be explained in the comment section on the following page,and will require follow-up action. <br /> comments: 6 l r'NL_t C l I t�L`�r'L 1_i -1a z O l Tl�t1 F'1vl — f ti'I !�L(t I�r Zli�t G, <br /> rollow-up action required:_.)P(" b 1.1 LL i1 N P1 U(1 L C)11 ('C-K'T Do, f o R"F ttil i N L> D L rl C.�_k <br /> � oar <br /> Dealer/Manager Signature: <br />