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Designated Underground Storage Tank (UST) --perator <br /> Monthly Visual Inspection Checklist <br /> Facile Name: Date: •- 2_, <br /> - - <br /> -'Facilny Address: -7D <br /> city! Zi Code: <br /> Devi ed UST or Conducting the on: Lori Freshour <br /> International Code Council Certification#: 5220 <br /> Si "x— Phone: (916)826-1576 <br /> Item MONITORING PANEL ALARM HISMILY Y N NA <br /> 1 Monitoring system is.powcred on and in proper operating mode <br /> 2 Monitoring system is not currently showing alarms or warnings <br /> 3 Alarm history report/log for the previous month is available,and has been reviewed by the Designated UST Operator. <br /> teach a copy of the alavn history report/log to thisform i available <br /> 4 Each alarm for the previous month has been responded to appropnately. <br /> 5 Sensors loafed in the tank-top caalamment sumps have not alarmed in the past month <br /> 5a List all tank-top sumps where alarms occurred in the past month: <br /> Note:Sumps when-an alarm has occurred in the past month must be inspected unless a qualified service technician responaed to,and / <br /> properly addressed,the cause of the alarm. Attach documentation verifying appropriate service to this report <br /> If—P ins tion 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 substance. Sensors are property located <br /> Note Visual YkVwbon of&nps is in&jmps where an alarm has ocarmd in the past moritii for which there is no service record <br /> Y N Y N <br /> Sump Location: Sum 'Loca6on: <br /> Sump Location: Sum Location: <br /> Sump Location: Sump Location: <br /> 7 Spill containment structures are free of water,debris,and hazardous substance. <br /> Y N NA Y N NA <br /> Tank 1 -Contents L t K(L- V/ Tank 3-Contents <br /> Tank 2-Contents 10 2� % Tank 4-Contents - Ai tiL� <br /> 8 UDC areas are free of water,debris,and hazardous substance. Sensors are properly located <br /> Y N NA Y N NA <br /> Dispenser 1/2 Di nser 9110 <br /> Di user 3/4 y Dispenser 11/12 Ci <br /> Dispenser 5/6 y Dispeuser 12113 <br /> Dispenser 7/8 Dispenser 14/15 N l} <br /> PAPERWORK INSPECTION Y N NA DATE DONE <br /> 9 Monitoring system certification has been cornpleted within the past 12 months. r f - <br /> 10 Secondary Contairtrrlent tests have been completed within the regLired timeframe. NA 6,1- <br /> 11 Spill containment shucture et testing was completed within the past year. - <br /> 12 Tank tightness testing was completed within reWired timeframe. / <br /> 13 Line tightness testing was completed with required fimefrarne. nl <br /> 14 Other reWirad testing maintenance was completed within required timeframe. List test/maintenance items below <br /> Test/Maintenance: L I n 6 � C. <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> FACILITY EMPLOYEE TRAINING Y N NA <br /> 15 All facility have received the reWired on-thajob training within the past year. <br /> 16 All facAity employees hired within the past 30 day have received the reWired ort- ob training ,uq <br /> Note:Any answer of"N"should be explained in the comment section on the following page,and will require follow-up action. <br /> l <br /> Comments: F't "� L(1 11 1, h i � L;_�<�a✓r C�i-�- ��_ `i `i 1 �� (l <br /> Follow-up action required: L' 2 C,6 ' <br /> Dealer/Manager Signature: • Date: l I I U <br />