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Designated'Underground Storage'Tank (UST) Opemtor <br /> 'Monthly Visual Ins'pection Chet lcli�t <br /> Eacil Nath: <br /> Facili Address: r <br /> Ci Zip Code <br /> Designated UST Operator coed aitig-ate on; <br /> International Ce Couneil C Expiration Date; <br /> Si store: 1'hona: <br /> Y'r Yee N=No A-NotAtmileMe <br /> Item M ONITORINC PANED!ALARM HISTORY Y N NA <br /> I Monitorin teni is owored oa andis rt► r o erat1 trod®. <br /> 2 Mon torn stem is not even showin an aI or warnings. <br /> 3 ' Alarm history roport/log for the previous-month is available,and has been reviewed by the <br /> Desi UST armor. Attach u cv' o the alarm histo .'re ort/lo to this orm ' available. <br /> 4 Each alarm for the previous mouth bas bash res onded to a ro riatel <br /> 5 Sensors located in:tank-to conud=ent sum s haus•not alarmed iii the est month. <br /> Sri List all tank-top sumps ivhw-e alarms occurred;in the past month; <br /> Nvic Sw4pr where an.alarm has occurred to the part mo*h meant be Inspected unless a gual{lled service mohntci m responded to,and <br /> pTperly addressed,the a Stat of the alarm.Auach doauwntaiton W0,6ing aippropriate service to this report. <br /> 0$W fres etto».M rai aamtd,record results indtem 6,below. <br /> SYSTEM INSPECTION <br /> 6 Tank-top contait►metrtsWnp are free bfwafer,debris,arfd hazardous substance. Sensors are located properly, <br /> 77— ore:Vitya int cNon grams Is o ' aired s where an alarm has eaoarred m thepast month or which there tt no service record. . <br /> Y N <br /> Sum Location: r c <br /> §ymp Location: <br /> Sump Location.; Sump Lo on, <br /> Sum Location: Sum Location: <br /> 7__ .S i.l"contain a re-act� 'ee'trf veiater'de�isis .arid-h92oxer ub5tatrce. <br /> Y N NA Y. N NA <br /> Tank I-Contents: Tank 3-Contents: <br /> Tank 2-Contents: Tat1k 4 Contents; <br /> 8 Under-dispenser containment akeas are '06 water, ebr{s and hazardous substance. Sensors are locatedproperl . <br /> Y . .N ' NA Y 1. N NA': <br /> DYA eraser 1/2 Dispenser 9/10 <br /> Dls aartsor 3/4 Drs ensatr 11/12 <br /> D!s sneer S/6 Dls enser 13/19 <br /> DA"718- Drs "eraser, 15/16, <br /> PAPERWORK INSP1E;CTI(M Y N NA DATE SONE <br /> 9 Monitorin systent certifies;ip0 AvoinpleUdmithin past 121nontha, <br /> 10 Secon containment testa have brs1 co' lett withhf the r aired timeframe, <br /> 11 S l 1 Containment structure. .Mg eQ sqn +.. co feted within the ear. <br /> El ink ti tress testin was coot Ieted wl#hi - ' uir'ed Line ti tress tes ' was Completed thin required� t mefixno, <br /> 14 Other Mijiired testi maintenance Was com let within aired timefranne. 1st aest/mainteixance items below: <br /> 7'est/Mairttenance: <br /> Test/Maintanance;: <br /> Test/Malntenance: ' <br /> FACILITY EMPLOYEE TRAINING X N NA <br /> 1.5 All facili em to sett have raaeived the t*ed Mft within the past year. <br /> 16 All'facili em lb ees hired within the past 304aya have received the tssuirpd on-the-job training. <br /> Now Any answer ofµN"•should be eitplalned In the comment section ora the following page,and will require <br /> follow-up action. - <br /> Oke I of 2 November 2004 <br /> Ed WdET:20 S00Z Z0 ObSZ Ta.E 9TG: 'ON XtUA E3NUN31NIUW NOI1ti1S30I0113S'Z'H: WONA <br />