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05/02/2008 09:42 FAX ► SJEH IM003/005 <br />MouthI4 Inspection - Page 2 of 2 <br />Mw <br />PAPERWORK I NSIDECrTON Y N NA _Datc Done <br />Monitoring sy,,,tern certification (within past 12 months <br />,,,Pill L111cicet testing completed (within past 12 months _3 2 1 <br />st 12 -)on.hs ) <br />The above aro untally done fiig u'd re.r"Idate)l! <br />(.!Iher on an annual basivfi)r lo <br />Lill.... Tightness (usually upon construction oc when no positive shutdown) <br />Tank Tightness (usually only of constniction t)r when usirjE.S�... <br />containment (STB989) tests have been com2leted (usual) cycry 3 ps.) <br />(m, lesting or maintenance cornpleted as required. List them beI0141: <br />i'est/Maintemince: <br />;esUMaititcnance: <br />_-Cc,nments: <br />Itc ills Requiring follow -u2 Actions: <br />Monthly inspection DIU.St be conducted by an ICC' licensed Desi&rnated Operator. <br />A copy of this checklist must be provided to UST owner or operator, but not to State Water Resource~_ <br />DesignatedOperator must alert the UST owner or operator of any condition discovered during the <br />Mondily* inspection that may require follow-up aQtion' — <br />UST owner or operator must maintain a copy olthis monthly inspection kind any attachi-nents for the <br />previous 12 months. Records niList be maintained on-site or, if approved by the local agency, off-site at <br />a readily available location. <br />