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R 'V <br />`J <br />kyj ! ! ,"_ <br />Facile Name: vv`i yam= S y, `a <br />Date: <br />Facility Address: i5-�:,, rade <br />Monitoring system is powered on and in proper operating mode. <br />City: 5 c." <br />CA Zi Coder <br />Designated UST Qperator Conducting the Inspection: <br />VII <br />International Code Cgumil Certification #: 14-_ 1-- <br />1 G Expiration Date: / `3 / <br />Si ature: <br />Phone: 53U) C -- cC C- <br />1eH—liV6H L6:IIV1C <br />Item MONITORING PANEL / ALARM HISTORY JYJ NINA <br />1 <br />Monitoring system is powered on and in proper operating mode. <br />2 <br />Monitonng 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 />Desi ated UST Operator. Attach a copy o the alarm history report/logreportIgg to this orm i available. <br />i <br />4 <br />Each alarm for the previous month has been responded to ro riatel . <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: 4_6d cac, 4 1 t,",;1c$ <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 />I sum ins ection is re uired, 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 sum s is only re uired in sum s where an alarm has occurred in thepast month or which there is no service record. <br />Y N <br />Y N <br />-Sump Location: L) <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 hazardous substance. <br />Y N NA Y N NA <br />Tank 1 - Contents: t 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 properly. <br />Y N NA Y N NA <br />Dispenser I / 2 Dispenser 9110 <br />Dispenser 3 / 4 Dis enser 11 / 12 <br />Dis enser 5 / 6 Dispenser 13 114 <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. _ c: <br />H Spill containment structure(bucket) testing was completed within the past year. <br />12 Tank tightness testing was completed within required timeframe. <br />13 Line tightness testing was completed within required timeframe. <br />14 Other required testing/maintenance was completed within required timeframe.(List test/maintenance items below. <br />Test/Maintenance: <br />Test/Maintenance: <br />Test/Maintenance: <br />FACILITY EMPLOYEE TRAINING Y N NA <br />15 All facilityemployees have received the required on-the-'ob tra m within the past year. <br />16 All facili em to ees hired within the ast 30 da s have received therequired on-the-'ob trainirt . <br />Note: Any answer of -Nn should be explained in the comment section on the following page, and will require <br />follow-up action. <br />Page 1 of 2 <br />November 2004 <br />