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N <br /> 0 '_0 CD <br /> p) signatcd Ur1dergtou1_d Stti' ati �p -i N ffl <br /> (UST")Op� �g��� O O o <br /> W Monthly Visual inspection Choc klist "t <br /> (D *t�ttc. ------__ Data 66/611201 R � N <br /> 170 Fv Hammrr Laine _ --� <br /> ____ 'nss l xlc. 95216 ---i <br /> min ranJucung the Insp conn \tack Ratim en !ip <br /> .1,57 Ope <br /> Certification <br /> tion# 88b7893 <br /> tic, ;wpretitrun D:itc [2/27 1 20 1 4 <br /> t— <br /> L__nc.�(9�.!ty AbAbll-5280-52gt1 <br /> CD <br /> fll 1t0V1i'ORI\G PANEL—'-- v v v-� ���� 4 <br /> Z '` ALA Rill NIST <br /> tt ytonitorinit gyatcm rs pow' d on tnd in proper operating <br /> O <br /> i s tem is not currcntiv showin t any alarms or vramings. 7 <br /> oniforuot•Y b <br /> M history repoit9ag Peat the{7cvxtuI txumth i4 avatlabte,and has been revtevvedby the Designated y t <br /> 3 rotor. (Att.tch a copy of the alarm history report.illogto this form if available-) -s <br /> N <br /> adt alamt for the previous~month has been respcm feet to—pp-0pt truly � <br /> jjsais located in tank-top containment sumps have t tit alarmed in the tilt m rnthk X <br /> . isI ail twtk-top sumps where alarms occurred to the past mooch: <br /> ,fytyrytxs i+'trete an t?7~srttr hoc orc'rurrd irr the pncz r c,th tt !L,msr !e �Ys'et <br /> dddre+'.trErl;the eattve+l`(he rrJntmt 111tnch doctonetttrzn� rr "/ re q,tn pt e w t7w r�,Jnr r Ir�,wp rrepreno=l to r,aarred. e.nrd rrsu <br /> 7n item d,he7ntr. <br /> INSPE(( m", <br /> Tank-top containment sumps are fi ee of water detrrts roti h z u('out substance Sensors are <br /> ,ynt, fti+ul .,_t vntps r,cnnrt.,V+ri>,d rn rnnMHha x^ttnr�,i; Itr ,r, ter.r a ;, null O <br /> „ •gut s- fi'''t <br /> ' ; <br /> StiLocataotny s r:r rr rt <br /> SUMP L0471L1077 °a Sump Location: to <br /> Sunrp Location: <br /> Sump Lacattvrr` `` <br /> spill c mlanut on struame;wi TOO! _ter,dchri,.and hi/ardous substance. _- <br /> -V N <br /> 1 <br /> )c Yang x `C <br /> Tank-89 X <br /> "R Cinder-dispenser containment areas are free of water_debris,and hazardous substance.Sensors are located property. <br /> Y N NA <br /> Y N \A _ �• <br /> Dispenser 1/2 X <br /> Dispensei-3=4 X O <br /> Dispe1jsz"r-5i6 X <br /> Dispe7ascr-' X O <br /> PAPERWORK INSPECTHM <br /> Monitoring systean certification has been euut Meted tiitltin tat I2 m m i s X -------- cp <br /> i pt r— it,i l- <br /> p Secondary containment tests have been completed 4vithin the required tilnct Jr11 �� �X T_ ,n,t, <br /> I Spill containment structure(bucket)testing <br /> tivas completed within the past icor _ ----. <br /> �2 Tanktighmess testing was completed within required timeframe .-- <br /> Line tightness testing was completed within required timefratne. <br /> ` (3thcr required Iesting/maintenance wad eornpleted within require tun ironic.(Li;t testmaintcX�e(tern'b <br /> l; TestiNfattitenance: -- <br /> ' ?'crstfh9auitena7x•�� <br /> j I t`st�'k9/7a7ttr;itC�ncc: <br /> FACILITY EMPLOYEE TRAINING X <br /> All f telli[y Ump)o�ce hnr ic�tkl`ti 'irc s )tiu�d un the 1 to tr tri in_ tion the p t,tc a <br /> .n,iii t„}i:r cc r lured vwilhiu I9l past 30d t s II tr z� cit th ityuilcd on-tnew�h Uainm �7 <br /> ID <br /> Any ailkoer of-11”should he exphd ied in the conluten(section un the ful►o1r tng PageO <br /> a <br /> d <br /> 'T1 <br /> O <br /> � - N <br /> >v W <br /> (D ~ <br /> N <br /> N N <br /> O <br /> W <br />