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Designated Underground Storage Tank (UST) Operator <br />Monthly Visual Inspection Checklist <br />Facility Name:Date: <br />Facili Address: <br />Cit ::1 <br />?,I-/ <br />Code: 95940 <br />Desi na ed T erator Conductingthe Ins ection:Ke i <br />Kis i a <br />International Code Council Certification #5 2 4 9 0 2 7 — U C <br />Expiration Date: 1 / 2 8 / <br />Si nature: <br />Phone: 2 0 9 )368-0603 <br />�--�' Y = Yes N = No NA = Not Applicable <br />Item MONITORING PANEL / ALARM HISTORY N 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 copy of the alarm history report/logreport/log to thisform if available. <br />4 Each alarm for the previous month has been responded to appro2riately. <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 verging appropriate service to this report. <br />It'sump inspection is required, record results in item 6, below. <br />B12111111111111 I 11111111M <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 occurred in the past month or which there is no service record. <br />Y I N N <br />Y d <br />9 Monitoring system certification has been completed within past 12 months. <br />10 Secondary containment tests have been completed within the required timefram <br />H Spill containment structurebucket testin was completed within the pastyear. <br />12 Tank tightness testing was completed within required timeframe. <br />13 Line ti htness testing was completed within required timeframe. <br />14 Other required testing/maintenance was completed within required timeframe. <br />Test/Mainienance: <br />Test/Maintenance: <br />test/maintenance items <br />Page 1 of 2 November 2004 <br />oump jocarion: <br />I <br />no= <br />Sump Location: <br />Sump Location: <br />Sum 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 NA <br />I <br />Y <br />Tank 1 — Contents: <br />'' Tank 3 — Contents: <br />Tank 2 — Contents: "' Tank 4 — Contents: <br />Under -dispenser containment areas are free of water, debris, and hazardous substance. <br />Sensors ar4DATE <br />8 <br />N NA <br />Dis enser 1/ 2 <br />✓ Dis enser 9 / 10Dis <br />enser 3 / 4 <br />Dis enser 11 / 12Dis <br />enser S / 6 <br />Dis enser 13 / 14Dis <br />enser 7 / 8Dis <br />enser 1 S / 16PAPERWORK <br />INSPECTION <br />N N <br />Y <br />9 Monitoring system certification has been completed within past 12 months. <br />10 Secondary containment tests have been completed within the required timefram <br />H Spill containment structurebucket testin was completed within the pastyear. <br />12 Tank tightness testing was completed within required timeframe. <br />13 Line ti htness testing was completed within required timeframe. <br />14 Other required testing/maintenance was completed within required timeframe. <br />Test/Mainienance: <br />Test/Maintenance: <br />test/maintenance items <br />Page 1 of 2 November 2004 <br />