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11 <br />Designated Underground Storage Tank (UST) Operator <br />Monthly Visual Inspection Checklist <br />Facility Name: tj <br />e,*,T7 gj S c -,P— <br />I Date: k— -7 <br />Facility Address: <br />%5-32- 0 <br />City: <br />C-^ <br />r Zip Code: R 5 2-Z-) � <br />Designated UST <br />Operator Conducting the Ins pection:7-- VN <br />,)c <br />International Code Council Certification #: �- ->-,4L -�S­79J - 0 j: _:�Ex <br />iration Date: <br />I Signature: <br />Phone: ( 7 3 c? ) 6 RC) -- 1_-`1 c 157 <br />---------- <br />Note: Any answer of 'IN" 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 />I <br />Monitoring system is owered on and in Rojjr op=n 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 />Desi2ated UST Operator. (Attach a copy of the alarm history report1log to thisform if available) <br />— <br />4 <br />Each alarm for the previous month has been respnded 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: — tict-,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 />Q""n,is Muired, 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 re uired 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 />Sum Location: ^j ee4 eA <br />S um Location: <br />Sump Location: <br />Sum Location: <br />I 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: 0 V,� 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 )roperly. <br />V I N NA Y N NA <br />Dispenser 1/ 2 Dispenser 9110 <br />Dispenser 3 / 4 1 Dispenser 11 / 12 <br />Dispenser 5 / 6 Dispenser 13 114 <br />Dispenser 7 / 8 Dispenser 15 116 <br />PAPERWORK INSPECTION Y_ N NA DATE DONE <br />9 Monitoring system certification has been completed within Rast 12 months. X G - -,-?_ (-- <br />10 Secondary containment tests have been completed within the required timeframe. N/ <br />H Spill containment structure (bucket) testing was completed within the past year. A <br />12 Tank ti tness testing was completed within required timeframe. <br />13 Line tightness testiN was completed within required timeframe. <br />14 Other required testinmaintenance was completed within required timeframe. (List test/maintenance items AvInw.) <br />Test/Maintenance: <br />Test/Maintenance: <br />Test/Maintenance: <br />77 <br />7,77777 77�7_77,, —7 <br />FACILITY EMPLOYEE TRAlN]NG Y. N NA <br />15 All facility employees have received the required on-the-job training within the past year. X_ <br />16 All facility employees hired within the past 30 days have received the required on -the job training. <br />Note: Any answer of 'IN" 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 />