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Designated Underground Storage T (UST) Operator <br />f` Monthly Visual Inspection Checklist <br />Faclll Name: <br />,- c o ' c_E' <br />I Date: 10 - ,g> C Co <br />Facility Address: <br />Mm, z- Aj. B, -p �0 <br />2 <br />Ci <br />cjc.. ve <br />Zi Code: S?mss <br />Desi ed UST Operator <br />Conducting the Inspection: <br />.� Z t,vs n..✓s <br />International Code Council Certification #: 3"7 9( -(IG <br />Expiration Date: / Z'? / DlP <br />Signature: <br />0.6�Phone: <br />Designated UST rator. Attach a copy of the alarm history rqwqLog to thisform i available. <br />S�3 O h$Cj- Z-0. 0 !�7- <br />Y = Yes, N = No, NA = Not Applicabie <br />Item MONITORING PANEL / ALARM HISTORY Y I N I NA <br />1 <br />Monitoring stem is powered on and in E2per operating mode. <br />2 <br />Monitoring stem 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 rator. Attach a copy of the alarm history rqwqLog to thisform i available. <br />4 <br />Each alarm for the previous month has been responded to appropriately. <br />5 <br />Sensors located in tank -!op containment sumps have not alarmed in the past month. <br />5a <br />- List all tank -top sumps where alarms occurred in the past month: -f' ad o -(d et U ff I tn.� <br />It py4Wu LV.so7e=C EyA- <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 />!sumpffsump inspection is re wired, record results in item 6, below. <br />6 Tank -top contai <br />Note: Visual in <br />Sump Location: <br />Sump Location: <br />"r7 <br />8 <br />UST SYSTEM INSPECTION <br />sumps are free of water, debris, and hazardous substance. Sensors are located properly. <br />sumps is only required in sumps where an alarm has occurred in the past month for which there is no service record. <br />Spill containment structures are free of water, <br />Y <br />Tank 1 -Contents: L?Yt <br />Tank 2 - Contents: <br />Under -dispenser containment areas are free of <br />1/2 <br />3/4 <br />5/6 <br />7/8 <br />Sump Location: <br />Sump Location: <br />1 and hazardous substance. _ <br />NA _ <br />Tank 3 - Contents: <br />Tank 4 - Contents: <br />debris, and hazardous substance. Sensors are <br />NA <br />Dispenser 9110 <br />Dispenser 11 / 12 <br />Dis enser 13 / 14 <br />Dispenser 15 / 16 <br />lall <br />PAPERWORK INSPECTION Y N NA I DATE DONE <br />9 Monitoring system certification has been completed within past 12 months. <br />10 Secondary containment tests have been completed within thereuired timeframe. <br />11 Spill containment structure(bucket) testing was completed within the past year. <br />12 Tank ti tness testing was completed within required timeframe. <br />13 Line tightness testi!!was com leted within re uired timeframe. <br />14 Other required testin maintenance was completed within re uired timeframe. List test/mainten nce items below. <br />Test/Maintenance: <br />Test/Maintenance: <br />Test/Maintenance: <br />FACILITY EMPLOYEE TRAINING I Y I N NA <br />15 1 All facility employees have received the required on-the-iob training within the past vear. <br />16 1 All facility employees hired within the past 30 days have received the required on -the job training. L " i <br />Note: Any answer of 6IN" 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 />