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u <br />II <br />:7 <br />ADesignatefUndergrr r Storage perator <br />Month1v Visual r <br />Facili Name: <br />_ Date: =3. —(v -% <br />Facility Address: i S 3 Z <br />fO< F <br />Ci S t -..P+ <br />N <br />Zi Code: - <br />Designated UST Operator Conducting the Inspection: <br />International Code CouReitCertification <br />#: ,S--2_ -l' <br />C_ Ex iration Date: t) /Z / Off <br />Si tune: <br />Phone: S3 <br />Y — Yes, N=No, NA=NuiAp ucauic <br />4 i <br />Item MONITORING PANEL / AL STORY Y N NA <br />1 <br />Monitoring system is powered on and in pLoTer operating mode. <br />2 <br />Monitoring system is not currently showing any alarms or warnin s. <br />3 <br />Alarm history report/log for the previous month is available, and has been reviewed by the <br />Designated UST Operator. Attach a cqpy of the alarm history report/7oreportl7og to this orm if available. <br />4 <br />Each alarm for the previous month has been responded to a ro riatel . <br />5 <br />Sensors located in tank -top containment sumps have not alarmed in the past month. <br />5a <br />- List all tnk-top sumps where alarms occurred in the past month: i1--�--s <br />�® it-xS> <br />Note: Sumps where A 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 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 sums is only required in sums where an alarm has occurred in the past month or which there is no service record. <br />Y N <br />Y N <br />Sump Location: <br />Lump 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 Y N NA <br />Tank 1 – Contents: Tank 3 – Contents: <br />Tank 2 – Contents: Tank 4 – Contents: <br />8 <br />Under -dispenser containment areas are free of water, debris, and hazardous substance. Sensors are located pro erl . <br />Y N NA Y N NA <br />Dispenser 1 / 2 Dis enser 9 / 10 <br />Dispenser 3 / 4 1 Dispenser 11 / 12 <br />Dispenser S / 6 Dispenser 13 / 14 <br />Dispenser 7 / 8 Dispenser 15 / 16 <br />PAPERWORK INSPECTION Y N NA DATE DONE <br />9 Monitoring system certification has been completed within past 12 months. <br />10 Secondary containment tests have been completed within therequired timeframe. C; <br />11 Spill containment structure bucket testing was completed within the past year. ca <br />12 Tank tightness testing was completed within required timeframe. <br />13 Line tightness testing was completed within required timeframe. <br />14 Other required testin maintenance was completed within required timeframe. (List test/maintenance items below. <br />Test/Maintenance: <br />Test/Maintenance: <br />Test/Maintenance: <br />FACILITY EMPLOYEE TRA G Y I N INA <br />IS All facility employees have received the required on-the-job training within the past year. <br />16 All faciltLqTkloyees hired within the past 30 da s have received the required on-the-'ob trainin . <br />Note: Any answer of "N" should be explained in the comment section on the following page, and will require <br />follow-up action. <br />Page 1 of 2 November 2004 <br />