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06/05/15 03:09PH HP LASERJET FAX 2099551865 P.10 <br />0 RECEIV U) <br />Designated Underground Storage Tank (UST) Operator 1� <br />Monthly Visual Inspection Checklist <br />ac nVft . . .. ...... <br />.... <br />Namelfammer I-5 A <br />_Eacil ityAddre52J.1,L5 ...... ITAL <br />SiVL,Stqektqtk Ca Zi CO& 95207 <br />=MT <br />_ga�pnitcAUST J e 1. �S!�.c 10!!' le Meeks with !Tamen-Hill Corp. <br />_jT <br />IntemAtional code coancii Certification 4: 818875-3-0c at�., 1-18-2015 <br />P P <br />hone: 9 ) S5805�3367 <br />V _�L V - Yep 'N--N0'.N..A1N'6tA lieahtc <br />Item MONITORING PANEL l ALARM -HISTORY <br />_W0­nR01jQ&nL SP ed and in r o Crating mode. <br />�t�qi.L on <br />'Stanis Cur ntl 'Showi WkV alarmas or vi"ImIngs. x <br />Mq!4 --n—.1 <br />3 Alarm history repott/log for tile previOus month is available, and has tymn Tcvimod by t1w x <br />rated UST Operator. (Attach qS.jt�ty, _of_i_iqe alarm histary r�)rllew to this 14rn1,ff'.q 't JqbLe)_"' <br />4 Each }ami for the previous Month !S!Mkd to appropriatc! <br />x <br />3- _Sens6r5 lormed in not alarmied in !t1q pa5t RnUEIt}1 <br />KI List till tank-topsumps si,hem alarms excurreil in the past month, . ...... <br />. . .. . ....... <br />Z7 whore an alarm hos, occurlyed mthe past month must he Inspit'redunfes.i a techmoan rexjxmdoi lo, and <br />property addressed, the cause pfrht,- ajc7n)I.Atfazh documemollon wriffing appy-opriweservice to rhN report, <br />;wvord resy/m j?, ireyp 6, below <br />USTSYSTEM INSPECTION <br />Tank -top containment sualps �j.rc gree of water, debris, and hazardous substance. Sknsom are located properly. <br />j f ej in s ere an alarm has accurred in the post t no sewvlrp r&.-ord. <br />-*Mme: Misual in to J, <br />Y N <br />V N <br />_LSuUi ) Location: <br />Location: <br />Calion, Sump Leation; <br />Th <br />_§0Lj Containinent structures ate free of water, debris, and hazardous substmice. <br />V N '&A N_ _NA <br />C %;k t- x Tank 3 - Conlents:PREVIUM <br />'rank x Tank 4 -, Contents; BU(...Kh,7S' x <br />)roper} 8 Under-di�AqN, r We free 0 s, and hazardmis substance. Sensors. are locates!)rppc <br />N N <br />IiNrk DiI.Q. mser 9;, 10 <br />Ser x <br />4 A' <br />JX.qmnser 73/14 se <br />_J19isEens�, 7 /8 .nMx <br />PAPER'. O , RK I , NSPECTION DATE DONE <br />(T- certification has been completed within p1st 12 111011ths, x <br />16-12 <br />2cont4qmem tests hmve beco cx) jipjqet! mcfrmne. x <br />sinicture (backet) <br />12 Tank (m.q1.4 testit% v Om leted within mjuired titneframe. . . .... <br />. ..... . yqjs cp_p k�q.within mquired <br />1-3 k_ 1-_'___...._--- <br />o lestImaintenanq Ilems below.) <br />14 Other <br />Coln d timerratne. (L,i,% <br />'liest,Maintenance: ...... <br />7'est/.Waintenonee: <br />FACILITY EMPLoyrrrRAINING V N NA <br />�15 A}l facility ctn la 'acs lsts c rec rived the re uir d opt -the ob traiilin vtit}tin t}xe si vear7.26-1 Z x <br />116 All frakilitv, ern lovecc h 011 th <br />!tired within the st 3011 da have r(.=. ived the re tfired on-thc-'ob ttraining.x <br />Now Any answer of "N" should be explained in the comment section an the following page, and will require <br />follow-up action. <br />