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s <br /> Designated Underground Storage Tank(UST)-System Operator <br /> Monthly Visual Inspection Checklist <br /> Facility Name: Date: S A x.26// <br /> Facili Address: 13 7S_.tv <br /> Ci so Code: <br /> Designated UST Operator QWducting the ection: <br /> ICC Cert.#: Exp.Date: <br /> Signature: Phone: <br /> V Yes,N-No NA-NotApplicatile <br /> Item# MONITORING PANEL/ALARM HISTORY YI N I NA <br /> 1 Monipgri <br /> ing s stem is powered on and in pro er 2pSatinmode. <br /> 2 Monitorin s tem is not currentl shovwin an leak alarms. <br /> 3 Alarm history report/log for the previous month is available,and has been reviewed by the <br /> DesignatedUST Operator. Attach a copy of the alarm history re ort/log to this ins ection orm. <br /> 4 Each alarm for the previous month has been responded to appropriately. <br /> 5 Sensors located in tank-top containment sumps have not alarmed in the East month <br /> 5a _ List all tank-top sumps where alarms occurred in the past month: <br /> Note:Sumps where an alarm has occurred in the part month must be inspected unless a.qualified service technician rmpomled to,and <br /> properly addressed,the cause of the alarm.Documentation veri&ing appropriate service should be attached to this report. <br /> If sum ins tion is r wired.results should be recorded in item 6,below. <br /> UST SYSTEM INSPECTION <br /> 6 1 Tank-top containment sumps are free of water,debris,and hazardous substance. <br /> Note:r1sual inspection Ltsumps s is on uired in sunkm where an alarm has occurred in thepast monthfir which there is no service record <br /> YIN- Y N <br /> _2KTp Location.-• Su Location: 1 <br /> 'Sump Location: if I IV I Sump Location: <br /> 7 Sill containment strictures are fi=of water,debris and hazardous substance. <br /> Y - N I NA I Y N NA <br /> Tank I—Contents: Tank 3—Contents: / <br /> Tank 2--Contents: Tank 4—Contents: m <br /> 8' Under-dis eraser containment-areas are&ee of water,debris,and hazardous substance. <br /> Y N I NA I I Y N INA <br /> Dispenser 112 >P Dispenser 7/8 <br /> Dispenser 3/4 Dispenser 9110 <br /> Dispenser 5/6 Dispenser/l/12 <br /> 9 Leak detection is pLoperly located within�lmder-dispenser containment. <br /> Y I N I NA I Y I N I NA <br /> Dispenser 1/2 40 1 1 Dispenser 718 <br /> Dispenser 3/4 is eraser 9110 <br /> Dispenser 5/6Dis enser 11/12 <br /> .......... Q9 LUZ t• <br /> PAPERWORK INSPECTION JYJ N NA I DATE DONE <br /> 10 Monitoring s tem certification has been completed within past 12 months. <br /> I I Secondarycontainment tests have been completed within the required timeframe. <br /> 12 Spill containment structure(bucket)testing was completed within the past 12 months. <br /> 13 1 Tank tightness testing was completed within required timeframe. <br /> 14 1 Line tightness testing was completed within required timeframe. <br /> 15 Other required testis maintenance was completed within required timeframe. List test/maintenance items below. <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> FACILITY EMPLOYEE TRAINING Y N NA ` <br /> [!17 <br /> �AUfacHi!j <br /> ili to es have received the required on-the-job trainingwithin the past ar. <br /> a to ees hired within the East 30 days have received the required on-the-'ob training. <br /> Note: Any answer of"N"should be explained in the comment section on the following page,and will require A, <br /> follow-up action from the UST owner/operator. <br /> Page i of 2 <br />