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Desigi rd Underground Storage Tank (US' -)perator <br /> MonthlyVisual inspection Checklist <br /> FaciltEE: � Date: —p <br /> Facils : -7 b L-�i t�! C3� <br /> City: * I Zip Code: : Z <br /> Designated UST Operator Conducting the on: Lori Freshour <br /> International Cqde Council Certification#: Expiration Date: <br /> Si Phone: X916)826-1576 <br /> Item MONMRING PANEL ALARM HISTORY Y N NA <br /> 1 monitoring system is powered on aid in proper operating mode <br /> 2 Monitoring s is not ciarrently showing alarms or warnings <br /> 3 Alarm history report/log for the previous month is available,and has been reviewed by the Designated Us1'Opc ator. <br /> ttach a copy ofthe alarm history reportl log to thisform i available Y <br /> 4 Each alarm for the prcvious month has been respotuled to to . <br /> 5 Sensors located in the tank-top caatimment sumps have rot alarmed in the past month ft LaeR,M <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 responded to•and <br /> properly addressed,the cause oft*alarm. Attach documentation verrfying appropnate service to this report. N <br /> /sumpIfsump 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 substance. Sensors are property located <br /> Note:Vw"xkspachon of sumps is only reWred in sumps where an afgm has oocured in the t month for which there is no service record <br /> Y N Y N <br /> Sump Locabon.- <br /> Sump Location: Symp Location: <br /> Sum Locabon. Sum Location: <br /> 7 Spill containment structures are free a water,debris,and hazarck substance. :, <br /> Y� N NA Y N NA <br /> Tarsus 1 —Contents � Tank 3—Contents <br /> Tank 2—Contents 0 Tank 4-Contents V po k V t AI T <br /> P18 UDC areas are free of water,debris,and hazardous stbstarx . Sensors a5Dispeniseral <br /> ated <br /> Y N NA Y N NA <br /> Dispenser 1/2 y /10 w a <br /> Dispenser 3/4 1/12 A <br /> Di user 5/6 2/13 <br /> Dispenser 7/8 4/15 <br /> PAPERWORK INSPECTION YN NA DATE DONE <br /> 9 Morutonng system certification has been cornpleted within the past 12 ft."_ o <br /> 10 Secondary Contairrrlent tests have been cornpleted within the required timeframe. <br /> 11 Spill containment shleture et testing was completed within fhe past year. <br /> 12 Tank fightness testing was=npleted within required timeframe. <br /> 13 Line tightness testing was completed with required timefrarne. <br /> 14 Other required testing maintenance was completed within reWired timeframe. List test/maintenance items below <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> FACILITY EMPLOYEE TRAINING Y N NA <br /> 15 All facility ees have received the rewired on-thejob train within the past <br /> 16 All facility ees hired wittrn the past 30 day have r6ceived ft required on training <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: S E3 cl S ot n LL r_7 A u 1,2-1 1 n 1 Q f <br /> Follow-up action required: <br /> Dealer/Manager Signature: Date: �— <br /> r . <br />