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1 <br />Designated Underground Storage Tank (UST) Operator <br />Monthly Visual Inspection Checklist <br />Facility Name P _1-7� !rQWLj1<�&_ <br />Date: <br />Facility Address: /-C-3;7- ArLq <br />Sum Location: L2161 <br />p Location: <br />Sum <br />City: <br />Zip Code: <br />Designated UST rator Conducting the ection: <br />Monitoring system is not currently showing any alarms or warnings. <br />International Code Council Certification #: g?=:q-37Rt_L)C, <br />Expiration Date: <br />Signature: <br />Phone: Cc., Cc.,SQ- ZqoS- <br />W <br />Y=Yes, N=No, NA=Not A Hcable <br />Item <br />MONITORING PANEL / ALARM HISTORY Y N NA <br />Sum Location: L2161 <br />p Location: <br />Sum <br />I <br />Monitoring system is powered on and in ro er o rating mode. X <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 />I Sump Location: <br />Designated USTperator. 0 Attach a copy of the alarm history repo!jIloS to thisjorm if available) <br />( <br />4 <br />Each alarm for the previous month has been responded to appropriately. <br />5 <br />Sensors located in tank -top containment sum have not alarmed in the past month. <br />5a <br />List all tank -to sumps where alarms occurred in the past month: <br />NA <br />A -W Li bA6. <br />Tank I -Contents: Qv-,teAAe_j <br />Note: Sumps where an alarm has o1ccurred 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 />Tank 2 - Contents: <br />sumins�4section is record results in item 6, below. <br />guired, <br />6 <br />Tank -top containment sumps are free of water, debris, and hazardous substance. Sensors are located properly. <br />-P'Note: Visual inspection of sumps is only re fired in sumps where an alarm has occurred in the past month or which there is no service record. <br />Sum Location: L2161 <br />p Location: <br />Sum <br />Y N <br />N <br />Y <br />Location: <br />.......... <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 />I Y N NA I I Y N <br />NA <br />Tank I -Contents: Qv-,teAAe_j <br />I Tank 3 -Contents: <br />Tank 2 - Contents: <br />I Tank 4 - Contents: <br />8 <br />Under -dispenser containment areas are free of water, debris, and hazardous substance. Sensors are locatedprope <br />YN NA Y N <br />NA <br />Dispenser 112 <br />X_ Dispenser 9110 <br />Dispenser 3 / 4 <br />Dis enser 11 12 <br />Dispenser 5 / 6 <br />Dispenser 13 14 <br />Dispenser 7 / 8 <br />tDis sneer 15116 <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 />