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Designated Underground Storage Tank (UST) _perator <br /> Monthly Visual Inspection Checklist <br /> Facility Name: Date: —p •�' . <br /> 'acility Address: b yltb kL L"ID <br /> 111 City: •Zi Code: <br /> Designated UST Opeirator Conducting the Ins on: Lori Freshour <br /> International C Council Certification#: -FExpiration Date: <br /> Si ure: Phone: (916)826-1576 <br /> Item MONITORING PANEL ALARM HISTORY Y N NA <br /> 1 Monitoring sysigm is powered on and in proper operating mode <br /> 2 Monitoring system is not currently showing alarms or wml4ngs LDW FU [_ <br /> 3 Alarm history re /log for the previous month is available,and has been reviewed by the Designated UST Operator- <br /> (Altachacopy alarm histoLy report/log to this orm i available <br /> 4 Each alarm for the previous month has been responded to appro ate) . <br /> 5 Sensors located in the tank-top containment sumps have not alarmed in tlx past month ftLFrkYVt =12 <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 N <br /> properly addressed,the cause of the alarm. Attach documentation verifying appropriate service to this report. <br /> lj*sump 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 properly located. <br /> Note Visual inspection of sumps is only required in sums where an alarm has oocured in the past month for which there is no service record <br /> Y N I Y N <br /> Sump Location: Sump Location: <br /> Sump Location: Sump 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, Tank 3-Contents <br /> h Tank 2-Contents Me Tank 4-Contents V AWo K V t✓AI T- <br /> 8 <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 y Dispenser 9/10 WA <br /> Dispenser 3/4 Dispenser 11/12 A <br /> Dispenser 5/6 Dispenser 12/13 IV A• <br /> Dispenser 7/8 Dispenser 14/15 N A <br /> PAPERWORK INSPECTION Y N NA DATE DONE <br /> 9 Monitoring system certification has been completed within the past 12 months. <br /> 10 Secondary Containment tests have been completed within the recluired timeframe. <br /> 11 Spill containment structure bucket testing was completed within the past year. <br /> 12 Tank tightness testing was completed within required timeframe. <br /> 13 Line tightness testing was completed with required timeframe. <br /> 14 Other required testing maintenance was completed within required 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 employees have received the required on-thejob training within the past year. <br /> 16 All facility employees hired within the past 30 day have received the required on-the-job 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: <br /> A t-A <br /> IP A <br /> AL . <br /> Follow+tp action required: <br /> Dealer/114nager Signature: Date: <br />