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E <br />Designated Underground Storage Tank (UST) Operator <br />Monthly Visual Inspection Checklist <br />Facili Name: Gearg Kjqhjda Tnr-Date:rj <br />FacilityAddress: <br />City: <br />p <br />Zip Code: <br />Desi gna ed T 15Pp erator Con ductin the Insection:Ke T -Ti <br />Kis h i d a <br />International Code Council Certification #5 2 4 9 0 2 7 – U C <br />Expiration Date: 12 / 2 8 / <br />Si nature: <br />Phone: (209 )368-0603 <br />/ Y = Yes N = No NA = Not A lica6 <br />Item MONITORING PANEL / ALARM HISTORYN NA <br />Y <br />1 Monitoring s stem is powered on and in proper operating mode. <br />2 Monitoring system is not currently showing any alarms or warnings. / <br />3 Alarm history report/log for the previous month is available, and has been reviewed by the <br />Designated UST Operator. Attach a co o the alarm hi tory re ort/lo to this form i available. <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 past 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 past month must be inspected unless a qualified service technician responded to, and <br />properly addressed, the cause of the alarm. Attach documentation verifying appropriate service to this report. <br />if sum ins ection is re uired, record results in item 6, below. <br />UST SYSTEM INSPECTION <br />6 Tank -top containment sumps are free of water, debris, and hazardous substance. Sensors are located properly. <br />Note: Visual inspection o sum s is only required in sumps where an alarm has occurred in the past month for which there is no service re <br />Y I N ff-1`4_ Y <br />9 Monitoring system certification has been com leted within past 12atimeframe.— <br />I <br />t(A <br />,�- <br />10 Second containment tests have been com leted within the re ui <br />lS ill containment structure bucket testin was com lehin t 4- <br />12 Tank ti htness testin was com leted within re uired timeframe.4140ther <br />Line ti htness testin was com leted within re uired timeframe.� <br />required testing/maintenance was completed within required timeframe. List test/maintenance items below-) <br />Page 1 of 2 November 2004 <br />Sump Location: <br />Sump Location: <br />Sump Location: <br />Sump Location: <br />Sum Location: <br />Sum Location: <br />7 <br />S ill containment structures <br />are free of water, debris, and hazardous substance. <br />Y N NA <br />N NA <br />Y <br />Tank I – Contents: <br />1 Tank 3 – Contents: <br />Tank 2 – Contents: <br />/ Tank 4 – Contents: <br />8 <br />Under-dis enser containment areas are free of water, debris, and hazardous substance. <br />Sensors are located to erl . <br />Y N <br />NA <br />N NA <br />Y <br />Dis enser 1/ 2 <br />Dis enser 9110 <br />Dis enser 3 / 4 <br />Dispenser 11 / 12 <br />Dis enser S / 6 <br />Dispenser 13 114 <br />Dis enser 7 / 8 <br />Dis enser 15 / 16 <br />PAPERWORK INSPECTION <br />N <br />NA <br />DATE DONE <br />Y <br />9 Monitoring system certification has been com leted within past 12atimeframe.— <br />I <br />t(A <br />,�- <br />10 Second containment tests have been com leted within the re ui <br />lS ill containment structure bucket testin was com lehin t 4- <br />12 Tank ti htness testin was com leted within re uired timeframe.4140ther <br />Line ti htness testin was com leted within re uired timeframe.� <br />required testing/maintenance was completed within required timeframe. List test/maintenance items below-) <br />Page 1 of 2 November 2004 <br />