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jLILY?A,?(M- <br /> ode-95204 <br /> "te-C'! i ZiP C <br /> k <br /> -1 <br /> -ate. rn4d$e® 161h.20 06 <br /> Vsnature: 'k� A Date:JULY 26,2 <br /> No <br /> f=Yes N— NA= Nut R!Czb'e <br /> le? <br /> x <br /> aaAMIS oi warnings? x <br /> and has been revtewed icy <br /> ala,rn report/log to this form 1 <br /> M <br /> to appropriately? <br /> X <br /> ------ - NC�T alarmed in the past mont h? x <br /> ii i�curr'-d in the past month. <br /> ualified service technician responded to, <br /> :T=ntli musT be inspected unless a q <br /> f the ala.,m.At!ach documentation verifying appropriate service to this rePort-If SUMP <br /> -P-i mit in it 6. <br /> Sy <br /> -4em inspection <br /> us <br /> jja,4ardo� tsubs, <br /> ance.Sensors am located properly. <br /> -m has occurred in the past month fbr which there is no <br /> ;�Fpec!'—Of is only mquired in sumps where an alai <br /> —F—YT—N <br /> tion SUPREME I x I <br /> tion DEISEL x <br /> !on <br /> substance? <br /> Y N NA Y <br /> X �n PREME <br /> Tank 1.Contents UNLEADED Tank 3.Cc-tents S x <br /> ----I <br /> i Tatik 2.Conlents UNLEADED X Tank 4.Contents DOSEL x <br /> S. Under-disjiLenser containment areas are free of water.debris,&hazardous substance?Sensors!Mw�®rkin roperly <br /> Y N NA Y N- NA <br /> Dispenser 1&2 x DhpnM 9&10 x <br /> xDis nser 11&12 x <br /> 3m <br /> Dispenser 5&6 x _MmmmiLEi <br /> Dispenser 7&8 x Dispenser 15&16 <br /> Pa In N, Date <br /> Done <br /> 97 Monitoring system certification has been completed within past 12�ths?� X 7/06 <br /> 10. riment tests haw been completed within required timeframe? X 1/05 <br /> 11. Spin containment structure(bucket)tesilft was completed in the past year? x 7/06 <br /> 12. T, ti stesting was completed within required firrieftan-le? X 1/05 <br /> !!!5 <br /> t <br /> 1Une 3. tightness testing was completed within required timeframe? 1 x 1/05 <br /> ems bel <br /> 14. other required tesfing(maintenance was completed within required thineframe.(list tewmaint enance it <br /> Test Maintenance <br /> Test Maintenance <br /> Test Maintenance <br /> Facility Empk7M TmInIng Y N NA Date <br /> Done <br /> 15. All thave recehPed the required on the job training within ft past Year? X 6/06 <br /> 'Atmrequired on the job x <br /> All employees in 30 days have received the <br /> training? <br /> A...ny arswer of'N"-" W Vq"red Int mmmert section on the foilomnlg pW.arW vAll require fol -up action. <br />