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0 <br />01!2.1!2008 20:47 FAX <br />I�j 0 01 <br />Designated Underground Storage Tank (UST) Operator <br />Month) Visual Inspection Checklist <br />Facility Name: BjR)n Shell <br />Facilk Address: 341 W Main <br />City: Ripon <br />Designated UST Operator Conducting the 1 <br />Intermational Cpde Coun it Certification #: <br />Si u=: (/ <br />It_m <br />PAPEFtVtp <br />I <br />Monitoringne <br />s m is ower 4 on and in r <br />2 <br />Monitorin svatem Is not currently sltowin i <br />3 <br />:Hann W.%tory report : log for the prcvio" m <br />13 <br />r,4 trach a co o the alarm hist� reo ort; le <br />4 <br />Each alarm for the evious month hoc bean <br />5 <br />Sensory lo"od in the tank -to contai mcnt s <br />54 <br />List all rank -top sumps where alarms occur <br />.Dote; Sumps where an alarm has occurred in <br />RK INSPECTION <br />pleted within the <br />properly addressed, the cause of the alarm, , <br />NA DATE DONE <br />I sum inspection a required. record results <br />2 ip Code: <br />r tion: Lori Freshour <br />_i220353 - UC Expiration Date: 9/17/07 <br />Phone: T9 6 4=-7 _ ► ci �-t _ t —tG <br />Itr1l 1NITORiNG I Y NA <br />mod,;m� o tarn mod <br />u y lamts or waminigs Nr- E `f (3 4� <br />o rth tq available, and has been reviewed by the esignated L?�rator. <br />110 this form ifavailable) <br />re pondctl to appropnately. <br />a npa have not alarmed in the past month <br />2.1 in the past month:_ _ <br />t le pasrmonth inrut be inspecred unless a qualified sarvice mchnicinn responded to, and <br />'t rich documenration vertfi•ing opproprrate •wtwce to this r'eporr. <br />u Item d. below, <br />6 Tank -top containment sumps are free of w <br />Note: Visual ins icn of sumps is only r&pkad in s <br />SUMP Locapon: <br />Sump Location: <br />Sum Location: <br />7 Spill Containment structures are free of wat <br />Tank 1- Contents u PL_ <br />Tank 2 -- Contents P P <br />8 1 UDC areas are free of water, debris, and h <br />Dispenser 112 <br />Dispenser 3/ 4 <br />Dispenser 516 <br />Dispenser 718 <br />UST SYSTEM INSPECTION <br />e'er, debris, and hazardous substance. Sensors are property located, <br />,n ups where an alorm has occ ared m tho past month for which there is w sarvicd reco/d <br />t Sump Location: <br />a )um c.ocanon.• <br />Sump Location: <br />e�, debris, and hazardous substance. <br />_ Y N NA <br />_ Tank 3 - Conte) <br />I Tank 4 - Contel <br />:j;:ardous substanc , Sensors are properly located <br />3 <br />r <br />PAPEFtVtp <br />9 <br />Monitoringsystem certification has been co i7 <br />10 <br />11 <br />Seconds Containment tests have been can_ <br />Spill containment structure bucket testi �N' <br />12 <br />Tank tightness testin was Complated withir <br />13 <br />Line fi htness testis was eted with r <br />re <br />14 <br />Other fired testi maintenance was cord <br />test/ Maintenance: <br />h� <br />N <br />rest/Maintenance: <br />Test/ Maintenance: <br />Y <br />N NA <br />Y N NA <br />Dis enser 9/ f 0 <br />Dis enser 11 1 2 <br />N <br />DI r14/15 <br />h� <br />N <br />RK INSPECTION <br />pleted within the <br />Y N <br />st 12 months. <br />NA DATE DONE <br />ipleted within the r tim <br />red eframe. <br />as completed within the t year. <br />_ t -0-7 <br />iced timeframe, <br />uired timeframe. <br />ti <br />geted within required timeframe. List test/maintenance items below <br />L <br />t~Iq'(7 <br />-ACILITY EMPL( <br />15_ All facility employees have received the reguir--d on-thejob trait <br />16 AII facility empioyLms bared within the past 3C day have receivec <br />Nate: Any amwer of WI should be explained in the t:c mment section on <br />Comments - <br />Follow -up action required: <br />0 <br />Dealer I Manager Signature: <br />/ <br />Di enser J2 / 1 <br />'s arse <br />I_NING <br />the past year. <br />ad on -the= ob traini <br />ng page, and will re <br />Date: <br />follow-up action. <br />