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Designated Underground Storage Tank (UST) Operator <br />Monthiv Visual Inspection Checklist <br />Facility Name: <br />FacilityAddress: <br />City: <br />Date: 7-1-411 D 5 <br />Zip Code: <br />Desi nated T erator Conducting the Ins2ection:Kelli <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: (209 )368-0603 <br />Y = Yes N = No NA - Not Agplicable <br />Item MONITORING PANEL / ALARM HISTORYN NA <br />Y <br />1 Monitoring system is powered on and in proper operating mode. s <br />2 Monitoring system is not currently showing any alarms or warnings. d <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 appropriately. <br />✓ <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 />!sump inspection is required, record results in item 6. below. <br />UST SYSTEM INSPECTION <br />6 <br />Tank -top containment sumps are free of water, debris, and hazardous substance. Sensors are located properly. <br />Note: Visual inspection o stmt s is only required in sumps where an alarm has occurred in the past month or which there is no service record. <br />Y N <br />N <br />Y <br />Sump Location: <br />Sum - <br />um <br />Sump <br />Sum Location: <br />Sump Location: <br />Sump Location: <br />Sum Location: <br />7 <br />S ill containment structures are free of water, debris, hazardous <br />and substance. <br />Y N NA <br />N NA <br />Y <br />Tank 1 - Contents. <br />Tank 3 -Contents. <br />Tank 2 -Contents: -' <br />Tank 4 - Contents: <br />8 <br />Under -dispenser containment areas arefree of water, debris, and hazardous substance. Sensors are located ro erl <br />. <br />Y N NA N NA <br />Y <br />Dis enser 17 2 ✓ Dispenser 9 / 10 <br />Dis enser 3 / 4 Dispenser 11 / 12 <br />Dis enser S / 6 Dis enser 13 / 14 <br />Dis enser 7 / 8 Dispenser 15 / 16 <br />PAPERWORK INSPECTION N NA DATE DONE <br />Y <br />9 Monitoring system certification has been completed within past 12 months. <br />10 Second containment tests have been completed within the required timeframe. ,tat <br />11 <br />All] containment structure bucket testin was com leted within the aSt ear, v �Zt <br />12 Tank tightness testing was completed within required timeframe. tq <br />13 Line tightness testingwas completed within required timeframe. <br />14 Other required testing/maintenance was completed within required timeframe. List test/maintenance items be <br />T..0/A.f_.*_...--"----- <br />Page 1 of 2 November 2004 <br />