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0 0 <br />Designated Underground Storage Tank (UST) Operator <br />Monthly Visual Inspection Checklist <br />Facili Name:In c <br />Facility Address: <br />Date: <br />Cit <br />Zip Code <br />Desi na ed T or e i K <br />s aZ <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 3 8— 0 0 3 <br />Y = Yes N = No NA = Not Apvficab <br />Item MONITORING PANEL / ALARM HISTORY I I N I NA <br />Y <br />I Monitoring system 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 O erator. Attach a co o the alarm historyre ort/lo to this orm 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 Sump ins ection is re uired, record results in item 6, below. <br />EM INEENINEEM 11 SEEM= <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 for which there is no service record. <br />Y I N10 1_T`N <br />Y <br />Sump Location: Sum Location: <br />Sum Location: 0Sum Location: <br />Sum Location: Smocation: <br />7 Spill containment structures are free of water, debris, and hazardous substance. <br />Y N NA N NA <br />Y <br />Tank I — Contents: ✓ Tank 3 — Contents: <br />Tank 2 — Contents: ✓ Tank 4 — Contents: <br />8 Under -dispenser containment areas are free of water, debris and hazardous substance. Sensors are located r90 erl <br />Y N NA N NA <br />Y <br />9 Monitoring system certification has been completed within past 12 monaear, <br />-r 1 tolt'o <br />10 Second containment tests have been completed within the required t11 Sill containment structure bucket testin was com leted within the ✓12 Tank ti htness testin was com leted within re uired timeframe. &5.,'13 Line ti htness testin was com leted within re uired timeframe.,✓ �, �l <br />ZrA <br />14 Other required testing/maintenance was completed within required timeframe. List test/maintenance items below.) <br />Page 1 of 2 November 2004 <br />