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Designated Underground Sto-age Tank (UST) operator <br /> Monthly Visual Inspection Checklist• <br /> .'acility Name: Lj9 HELL. Date: .-" —D l� <br /> z,acdjiy ,Address: -til o <br /> City: r Zip Code: t <br /> Desi ed UST Operator Cond the on: Lori Freshour <br /> International Code Council Certification#: 220 ` --+- - — <br /> Si Phone: 916)826-1576 <br /> ltem MONYMIKING PANEL. ALARM HISMRY Y N NA <br /> 1 Momtormg system is powered on and in proper operating mode <br /> 2 Monitoring systm is not ently showing alarms or warmw F D <br /> 3 Alarm history report/log for the previous mouth is available,and has been revrewed by the Dewgnatod UST Operator. J <br /> ttach a copy of the alarm h i story report/Igg to this form if available !t <br /> Iw <br /> 4 Each alarm for the previous mouth has been responded to appropriately. ToI <br /> 5 Sensors located m the tank-top caatammeri sumps have■ot alarmod in the past month <br /> 5a List all tank-top 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 service technician respomdad to,and <br /> property addressed,the cause of the alarm. Attach dacumentahon verifying appropriate service to this report. <br /> lfsuj"p inspection is required,record results in item 6,below. s. <br /> UST SYSTEM INSPECTION <br /> 6 Tank-top contaimlent sumps are ftee ON",debris,and hazardous substance. Sensors are property kxated <br /> Note Visual of sum is n aimps where an alarm has ocarw in the n"Wh for wlrch there is no service record <br /> Y I N Y N <br /> Sump Location: Sump Location: <br /> Sump Location' Sum.p Limon.' <br /> Sump Location: Sump Location: <br /> 7Spill conta rtnent struchlres are free of water, debris,and hazardous substance. <br /> • Y N NA Y N NA <br /> t Tank 1 -Contents LA K L Tank 3-Contents `b t y <br /> T"2-Contents Pgj2 Tank 4-Conte& VEu 7-`'i GCwt/0 <br /> 8 UDC areas are free of water,debris,and hazardous substar>ce. Sensors are property located <br /> Y N NA I Y N NA <br /> Dispenser 1/2 Dispenser 9/10 N A <br /> Disperwr 3/4 gem--.o Cu L AcAKM Dispenser 11/12 N <br /> Dispenser 5/6 Dispenser 12113 N <br /> Dispenser 7/8 Y I Dispenser 14/15 N a4 <br /> PAPERWORK INSPECTION Y N NA DATE DONE <br /> 9 Monitor temtertrficabon has been tad within the past 12 monft. y -G <br /> 10 Secondary Contaimlent tests have been completecl within the reWred timeframe. <br /> 11 Spill conUmlelt et testing was=Tpleled within the V G- -o <br /> 12 Tank fightniess testing was completed within rWAred timeframe. <br /> 13 Line tightriess testing was conoeted with reWrad tirneframe. N <br /> 14 Oriier mcgired testi ntenance was wrroeted within reWrad timeframe. List test%maintenance items below <br /> Test/Maintenance: I-L p <br /> Test/Maintenance: _ <br /> Test/Maintenance: <br /> FACILITY EMPLOYEE TRAINING Y N NA <br /> 15 Ali facility have received the reorad on- training Mthin the past r. <br /> 16 1 All b614 ernployees hred witt>in the past 30 day have received the reWred on-tojob tarung <br /> Note:Any answer of"N"should be explained In the comment section on the following page,and will require follow-up.>iction. . <br /> comments: (` ig:g T -b t.0 <br /> Follow-up action required 5 R 6- DtZ, .itT c_[ L-4 .. . <br /> Dealer/Manager Signature: Date: Lf <br /> • rj <br />