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1 <br />Designatekanderground Storage Tank (UST) Operatj <br />Monthly Visual Inspection <br />Facili Name: ,p <br />Date: Z_-77-07 <br />Facility Address: (� C <br />Cl <br />Zip Code: S <br />Desi ted UST Operator Conducting the Inspection: <br />Monitoring system is powered on and in proper operating mode. <br />International Code Council Certification #: 2. �7p <br />C Expiration Date: / Z-7 / 6 <br />Signature: <br />Phone: S'3r ,-a o -- ;_-j c S" <br />`E <br />Y = Yes. N = No. NA = Not Anulicable <br />Item <br />I MONITORING PANEL / ALARM HISTORY <br />I Y I N INA <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 />3 <br />Alarm history report/log for the previous month is available, and has been reviewed by the <br />Designated UST Qperator. Attach a copy of the alarm history report/logreportfiog to thisform 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: H(a <br />Note: Sumps where an alarm has occurred in the past month must he 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 />I 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 sums 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 />Y N <br />Sump Location: Q v,„\ <br />Sump Location: <br />Sump Location: <br />Sump Location: <br />Sump Location: <br />Sum Location: <br />7 <br />Spill containment structures are free of water, debris, and hazardous substance. <br />Y N INAI <br />Y N NA <br />Tank 1 — Contents: e.e 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 3roperl . <br />Y N NA <br />Y N INA <br />Dispenser 1/ 2 K Dispenser 9110 <br />Dispenser 3 / 4 Dispenser 11 / 12 <br />Dispenser S / 6 Dispenser 13 / 14 <br />Dispenser 7 / 8 Dispenser 15 / 16 <br />PAPERWORK INSPECTION Y N NA <br />DATE DONE <br />9 <br />Monitoring system certification has been completed within past 12 months. <br />(0 —2-006 <br />10 <br />Secondary containment tests have been completed within the required timeframe. <br />-- 0-5— <br />„5'11 <br />I I <br />Spill containment structure(bucket) testing was completed within the past year. <br />% — r; co <br />12 <br />Tank tightness testing was completed within required timeframe. <br />13 <br />Line tightness testing was completed within required timeframe. <br />14 <br />Other required testing/maintenance was completed within reuired timeframe. (List test/maintenance items below. <br />Test/Maintenance: <br />Test/Maintenance: <br />Test/Maintenance: <br />FACILITY EMPLOYEE TRAINING <br />Y I N I NA <br />15 <br />All facility employees have received the required on-the-job training within the past year. <br />16 <br />All facili em to ees hired within the past 30 da s have received the required on -the job training. <br />I I I d <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 />