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A <br /> stn dl-v <br /> IJl acalisy <br /> 'n <br /> Facility Addr�sz.: <br /> city: <br /> Desigpa;-d UST, )pprator Cond-Licting th JJ_­,r-ty -otiffi Fninzt�n-ailj Corn, <br /> li-1—teniLliom.1 Ccda Council CerLification <br /> lion,Da�;� <br /> Signature: QgA_*-nLQ4 Phan,-: ( 559)h83-2977 <br /> C-14 Y Yes,N=No,NA Not A I'"""'—bi <br /> e <br /> el <br /> Item MONITORING PANEL ALARM HISTORY Y N NA <br /> I Monitoring cvqpm is I in proper operating mode.--- <br /> 2 Monitoring system is not currently showing any alarms or warnings. <br /> 1 <br /> 31 FA <br /> Alarm history report/log for the previous month is available, and has been reviewed by the <br /> Designated UST Operator. (Attach a copy of alarm history report/log to thisform if available.) y <br /> 4 Each alarm for the previous month has been responded to appropriately. <br /> 5 Sensors located in tank-top containment sum ps_have not alarmed in the past month. <br /> 5a List all tank-lop sumps where alarms occurred in the past month: Clf _5TP <br /> Note:Sumps where an alarm has occurred in the past month must be inspected unless a qualified service technician responded to,and <br /> properly addressed,the cause of the alarm.Attach documentation verifying appropriate service to this report. <br /> If 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 located properly. <br /> --*Note: Visual inspeclion of sumps is only required in sumps where an alarm has occurred in the past month for which there is no service record. <br /> Y N Y <br /> Sum Location: Sun Location: <br /> Sump Location: Sump Location: <br /> Sump Location: Sump Locatiow" <br /> Spill containment structures are free of water,debris, and hazardous substance. <br /> Y N NA Y N NA <br /> 'rank I -Contents: T Tank 3-Contents: <br /> Tank 2-Contents: Tank 4-Contents: <br /> _8 Under-dispenser containment areas are free of water, debris, and hazardous substance. Sensors are located pro perly. <br /> Y N NA _Y N NA , <br /> Dispenser 112 Dispenser 9110 <br /> Dispenser 3 4 Dispense 11112 <br /> Dispenser 5 6 )< Dispenser 13 14 <br /> Dispenser 718 )< Dispenser 15 16 <br /> v <br /> PAPERWORK INSPECTION Y N NA DATE DONE <br /> 9 Monitoring system certification has been completed within past 12 months. — )c —/-_/-3---I Z, <br /> 10 Secondary containment tests have been completed within the required timeframe. 2v <br /> '' Spill containment structure(bucket)testing was completed within the past year, X <br /> 12 Tank tightness testing was completed within required timeframe. C1-1 -Z. <br /> , <br /> 13 Line tightness testing was completed within required timeframe. <br /> 14 Other ng/nnaintenance Nya_s completed within required timeframe. (List test/maintenance items below.) <br /> Test/Allaintenance: <br /> Test/Afaintenance., <br /> Tes,!;',1,fa.`Wtnance: <br /> F,-,'.-./,_JLlTY EMPLOYEE TRAINING Y_ N <br /> yees ha,+c re �---i,-,"u-d the required on-the-'ob traini n,_3 wi thin the past year, <br /> 16past 30day's have.received the required on-thej,-btraii-Iina. <br /> Note: Any answer(it ­N11 should be explained in the comment section on the following page,and will require <br /> follow-up action, <br /> Page 1 of 2 September 2004 <br />