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DesignatefJnderground Storage Tank (USl Aerator <br />Monthly Visual Inspection Checklist <br />Facility Name: <br />Date: - -- <br />Facility Address: /-S-3'2— At <br />Monitoring system is powered on and in proper operating mode. <br />City: <br />Zi Code: _jg` <br />Desi nated UST Operator Conducting the Inspection: <br />2 <br />International Code Council Certification #: <br />Expiration Date: C1 / 2.72 / 0 <br />Signature: <br />Phone: 5'30 C Ci — Z� <br />Y = Yes, N = No, NA = Not A licable <br />Item MONITORING PANEL / ALARM HISTORY Y N NA <br />1 <br />Monitoring system is powered on and in proper operating mode. <br />2 <br />Monitoring system is not currently showing any alarms or warnings. <br />3Alarm <br />history report/log for the previous month is available, and has been reviewed by the <br />Desi ated UST Operator. Attach a copy of the alarm history report/logreporNog to this orm if available. <br />4 <br />Each alarm for the previous month has been responded to appropriately. <br />5 <br />Sensors located in tank -top containment sumps have not alarmed in the past month. <br />5a <br />_ List all tank -top sumps where alarms occurred in the past month: E_ <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 />!Lsump 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 sumps is only required in sum s where an alarm has occurred in the past month for which there is no service record. <br />Y N <br />Y N <br />Sump Location: t <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 Y N NA <br />Tank I — Contents: 3 —Contents: <br />__+_Tank <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 properly. <br />Y N NA Y I N INA <br />Dispenser 1 / 2 Dispenser 9 / 10 <br />Dis enser 3 / 4 Dispenser 11 / 12 <br />Dispenser 5 / 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 the required timeframe. <br />11 Spill containment structure bucket testing was completed within the past year. <br />12 Tank tightness testing was completed within required timeframe. <br />13 Line ti hmess testing was completed within required timeframe. <br />14 Other required testing/maintenance was comleted within required timeframe. List test/maintenance items below.) <br />Test/Maintenance: <br />Test/Maintenance: <br />Test/Maintenance: <br />FACILITY EMPLOYEE TRAINING Y I N I NA <br />15 All facility employees have received the required on-the-job training within the past year. <br />16 All facility employees hired within the past 30 days have received the required on-the-iob training. <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 />