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01/24/.008 20:53 FAX <br />I <br />Z003 <br />Designatoi Underground Storage Wank (US'i�' <br />Vlontfil Visual Ins ection Checklist <br />Date: 12. 101 <br />• <br />Item <br />IMj <br />1 <br />Monitai n system is owesod on a,td in <br />2 <br />3lotutorin syslam is oat can rattly ahowm .! <br />3 <br />r11um history report ! log for the previous m 3 <br />44 Hach a co o rhe alarm hisro ' ne rt; tc <br />4 <br />Each alarm for the vioos month has brdtt r a <br />5 <br />Sensors located in the tank -t oontaimtiem si <br />Sit <br />List all tank -top sumps whery alarms occnn <br />NOW Sumps where an alarm has occurred in t <br />properly addressed, the cause of the alarm. r t <br />! sum ins coon rs r� aired, record results , <br />6 Tank -top containment sumps are free of w <br />Note; visual ins tan of sum is and r ed in s <br />Sum Location: <br />Sum Location: <br />Sum Location: <br />7 S 'll containment structures are free of wal <br />Tank 1- Conterrts U 1 t� <br />Tank 2 - Contents <br />8 UDC areas are free of water, debris, and h: <br />Dispenser 112 <br />Di 314 <br />Di neer 516 E <br />Di user 718 <br />)U 9F2 -!J, T'� <br />Date 7 71-�b- <br />dh is available, and hoe been reviewed by the Designated UST Operator. <br />to thisorm i wmlabTeJ <br />poadcd to apptopriatclv.1? I� - is <br />a have trot alarmed in t t month <br />e <br />101 the past month; <br />le past month na,st be inspected ,in/i7ss a gtmt{fed service tachmcion responded to, oqd <br />ach doa,mentation-rtfyrng appropriate sdruice to chis report, <br />WIN A below, 7Tf) <br />Uel' SYSTEM INSPECTION <br />i or, debris, and hazardous substance, Sensors are pWerty located, <br />n .t s whom an alarm has oecumW in the Pad month for which there is no series record <br />YN'.�,. <br />Sum Loudon: <br />Sump Location: <br />'^'� �'Sum Location: <br />debris, and hazardous substance. <br />.N <br />Tank 4 -ContentsL IN <br />v ardous substance. Sensors are property located. - <br />_ PAPERNK <br />9 M011itOri!N system certification has been co-( <br />H <br />�Iill <br />Gontariment tests have been con <br />inment structure testi 'h. <br />&140ther <br />Tank ti htness teSU was atedwithir, <br />Line ti htrtess testi was cam le" with -Oc, <br />iced testi maintenance was car i <br />test/ Maintenance: _ <br />Teat/Ma ntenance: <br />Test/ Maintenance: <br />l reser 11112 <br />-- -[ <br />Di nser 12113 <br />KIN INWhU 1IUN Y N <br />Pleted within the Past 12 months. <br />NA DATE DONE <br />I _ 1 G - b Z <br />ed within the red timeframe, <br />93 OOVetad within the past year, y_ <br />-2--7--3 -7 <br />b <br />red timeframe, <br />N <br />ubred timeframe. <br />Meted within required timeframe. List fest/maintenarrce items below <br />µACILITY EMPLOYEE TRAINING -7-y7-N i NA <br />15 All facili L2T bo ees have re�e r r i ed on -the job training within the Past year, <br />16 Ail facili 0 ees tired within the past 30 Jay have received the Taired on -the= ob training N p <br />Note: Arty answer of "N" should be eupl ned in the cornment section on the following page, and will require follow-up action. <br />c s - ►1 i 6 lb -1, ► Lf o "1, -Zha 161 -015 P, 5- tp <br />Comments:__ `� �� 12 i�;=-;� U4c �' 1 ^TZ� G� b 12 R SGT a S t 7jok1 <br />Follow-up action required: <br />• Dealer i Manager Signature: <br />Date: <br />