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Designated Underground Storage Tank (UST) Operator <br />Monthly Visual InSuection Checklist <br />Facility Name: <br />Facility Address: <br />City: <br />Date: A - <br />Zi Code: 95940 <br />Desi nated T erator Conductingthe Ins ection:K e i <br />Kis i 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: 2 0 9 )368-0603 <br />✓ / �--� Y = Yes N = No NA = Not Applicab <br />Item MONITORING PANEL / ALARM HISTORY I I N I NA <br />Y <br />1 Monitoring system is powered on and in ro er 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 Oerator. Attach a copy of the alarm history report/logreport/log to thisform if available. <br />4 Each alarm for the previous month has been res onded 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 />IfsumD ins ection is re uired, record results in item 6, below. <br />MEMEVEM <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 re uired in sumps where an alarm has occIII_urred in the Past month or which there is no service re <br />Y N N <br />Y <br />9 Moni oring s vstern certification has been completed within past 12 months. -11 td`) 1. <br />10 Second containment tests have been completed leted within the required timeframe. <br />H Spill containment structure bucket testingwas Completed within the aSt ear. it�t lob.. <br />12 Tank ti htness testingwas completed within required timeframe. Zf27(t73 <br />13 �Other <br />htness testingwas com leted within required timeframe. la <br />14 required testing/mai was com leted within re uired timeframe. List test/maintenance items below.) <br />Page 1 of 2 November 2004 <br />ourrip . ucatton: <br />I I <br />EMO <br />Sump Location: <br />Sump Location: <br />Sump Location: <br />Sump Location: <br />Sump Location: <br />7 <br />Spill containment structures are free of water debris, and hazardous substance. <br />Y N NA <br />N <br />NA <br />Y <br />Tank 1 — Contents: <br />_ r Tank 3 — Contents: <br />Tank 2 — Contents: <br />Tank 4 — Contents: <br />8 <br />Under -dispenser containment areas are free of water, debris, and hazardous substance. <br />Sensors are located properly. <br />Y N NA <br />Dis enser 1 / 1 <br />r Dispenser 9 / 10 <br />Dis enser 3 / 4 <br />Dis enser I1 / Il <br />LDATEDONE <br />Dis enser S / 6 <br />Dis enser 13 / 14 <br />Dis enser 7 / 8111 <br />Dis enser 1 S / 16 <br />4NNA <br />PAPERWORK INSPECTION <br />Y <br />9 Moni oring s vstern certification has been completed within past 12 months. -11 td`) 1. <br />10 Second containment tests have been completed leted within the required timeframe. <br />H Spill containment structure bucket testingwas Completed within the aSt ear. it�t lob.. <br />12 Tank ti htness testingwas completed within required timeframe. Zf27(t73 <br />13 �Other <br />htness testingwas com leted within required timeframe. la <br />14 required testing/mai was com leted within re uired timeframe. List test/maintenance items below.) <br />Page 1 of 2 November 2004 <br />