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W I ) <br />I <br />Designated Underground Storage Tank (UST) 1"1 eratj <br />11,fi1t'1 y Visual Inspection Checklist <br />Facility Name: To A <br />Date: 9-?-CI7 <br />Facility Address: k S -162 00, A <br />IZ� <br />_ <br />City: sk-c!��xn I <br />Monitoring system is not c�ntl sh2Min& any alarms or warniMs. <br />Designated UST Operator Conducting the InMection:_��, <br />International Code QyMQ_Certification #: S2:47!57,Cz k - t 3c, <br />Expiration Date: 08 <br />Signature: V C1.1 <br />P 1, I <br />XT_ W W-1 A <br />MONITOR-ING PANEL / ALARM HISTORY <br />1 <br />Monitoring system is powered on and in proper operatiES mode. <br />2 <br />Monitoring system is not c�ntl sh2Min& any alarms or warniMs. <br />3 <br />Alarm history repoftAog for the previous month is available, and has been reviewed by the <br />Designated UST Operator.. (Attach a copy of the alarm history repormlog to thisjorm if availabIle- <br />4 <br />Each alarm for the previous month has been responded to appropriately. <br />5 <br />Sensors located in tank -to p containment sumps have not alarmed in the past month. <br />5a <br />- 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 of sumps is only required in sum s where an alarm has occurred in the past month or which there is no service record. <br />Y N <br />Y N <br />Sump Locat <br />Sum 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 <br />hazardous substance. <br />I Y N NA <br />Y N NA <br />Tank I - Contents: U JK <br />Tank 3 - Contents: <br />Tank 2 - Contents: I <br />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 I Y I N NA I <br />Dispenser 1 2 X_ Dispenser 9 / 10 <br />Lpenser 11 / 12 <br />Diseenser 3 4 Pu <br />41 <br />1Dis sneer 13 114 <br />Note: Any answer of "N" should be explained in the comment section on the following page, and win require <br />follow-up action. <br />Page I of 2 November 2004 <br />