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01/24/2008 20:52 FAX <br />� R <br />Facility Name: Ripon Shell <br />Facft Address: 341 W Main <br />City: Ripon <br />Desio=ted UST Cloerator Cots <br />i <br />Designated Underground Storage Tank ('GIST) Operator <br />-Wofithly Visual Inspection Checklist <br />Zip Code: <br />tutting the 1n, tion: Lori Freshour <br />ti hcation #, _3220353 - UC J Expiration bate: I b - b <br />U Phone:sla <br />ILetn <br />M <br />1 <br />Monitoring "am is pawgcd on vtd in pr <br />2 <br />toring sv;aam is not current) showing t <br />3 <br />Alarm history rtpw i log for the previous m <br />(attach a.g?ZL o 'the alarm history re rt; & <br />4 <br />Each alarm for the proviom month has bren rs: <br />5 <br />ns <br />Sensors located in the contaimttent S <br />53 <br />List all lank top sumps where alarmx occurs <br />Note: Sumps where an alarm hos occurred in <br />properly addreueld, the cause o/'the alarm. r <br />I slim inspection ret required, record res7rlts <br />6 Tank -top containment sumps are free of w <br />Note: Visual inowtion of sum is qnly req.4red in s <br />Sump Locadon: <br />Sump Location: <br />Sump Location: <br />7 Spill containment structures are free of wal <br />Tank 1- Contents to Ll (~ <br />Tank 2 - Contents <br />8 UDC areas are free water, debris, and h <br />Dispense 1/ 2 <br />Di enser 3/ 4 <br />DiAwnser 516 <br />Di nser 718 <br />Q001 <br />tNITOli1<NG PANEL AIARM HISrQRY Y N NA <br />o ti made <br />y alarms or waminFn a v1: - b tet til t <br />ah is available, and ha4 been rcvtcwa byd the Destgnatcd UST Qp xator. 11—)o "4)-7 <br />rothisformifavarlable) <br />panded to approprtntcIv. <br />W have: not akirmed in the p:44 month UP <br />l in the parr month; <br />,e past month mu.,t he inspected unless a qualified service Technician responded ro. and� n <br />rich documentation verifying appropriate service to rhis report r`1 <br />item 6. below. <br />__ I: <br />UST SYSTEM INSPECTION <br />a or, debris, and hazardous substance. Sermors are property located, <br />u ips where an alarm has oixured in the ead month for whIch there is no survxv record <br />Y N �j Y N <br />' Sump Location.• <br />er, debris, and <br />;�::ardous subst <br />— PAPERWORK INSPECT <br />9 Monitoring system certification has been cool ted within <br />10 Secondary Contairunent tests have been ccr ipleted within <br />11 Spill containment structure (bucket) testing n,js coWeted <br />12 Tank tightness testing was completed withintied hmei <br />13 Line lightness testing was completed with r(Kiuired timefrai <br />14 1 Other required testing maintenance was com >leted wil <br />Test/Maintenance: <br />Test I Maintenance: <br />TOW Maintenance: <br />r•ACILIT <br />15 All facilityo eas have received the requL ed on-tht <br />16 All facility to 's lured within the past 30 say have <br />Note: Any answer of "N" should be explained in the rnmment s <br />Follow-up action required: <br />• Dealer I Manager Signature: <br />azardous substance. <br />Y N j NA j <br />Y N W <br />Tank 3 - Conients <br />Tank 4 - Contents <br />iod. Sensors a roperly located <br />YI N T NA 1 <br />Dispenser 9110 <br />Di nser 11 / 12 <br />IbL <br />Dis nser 12 / 13t= <br />Dispenser 14115 <br />L� <br />)N Y <br />N NA DATE <br />a past 12 months. <br />ie reWired timeframe, <br />tithin the t year, <br />I - I e( — 0 <br />5-C- 7 75 - <br />t 1 q _D-1 <br />ime. N la <br />3. <br />fired timeframe, List test/maintenance items below <br />1_ - 03 <br />I 1-2t -a-t <br />ILOYEE TRAINING Y I N , NA <br />-a�ithin the past year. <br />T <br />red the required on-the-job training I IA <br />on the following page, and will require follow-up action. <br />J� IC �. s e <br />ilk 0 <br />Date: <br />