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Designated Underground Storage Tank Operator <br />Monthly i` i <br />Facile Name: tJK C <br />Date: _p <br />Facility Address: ( Z <br />Y N <br />City: 5 <br />2i Code: <br />Designated UST Operator ConductinZ the Inspection: <br />Sum Location: h <br />International Code Council Certification #: 52-,4 fit✓, <br />Ex irarion Date: O / Z_ / 'z.-00 (o <br />Si ature: <br />Phone: - <br />W- <br />Jim __ - - - - MONITORING PANEL / ALARM HISTORY ___ 0ME <br />1 <br />Monitoring system is powered on and in proper operating mode. <br />Y N <br />2 <br />Monitoring system is not currently showing any alarms or warnings. <br />Sum Location: h <br />3 <br />Alarm history report/log for the previous month is available, and has been reviewed by the <br />Sump Location: <br />Sump Location: <br />Sump Location: <br />Designated UST 2perator. Attach a copy othe alarm histo re rtRo to this orm i available. <br />Spill containment structures are free of water, debris, and hazardous substance. <br />4 <br />Each alarm for the previous month has been resp2nded to appropriately. <br />Tank 1 -Contents: jj &Tank 3 - Contents: <br />5 <br />Sensors located in tank -lop containment sumps have not alarmed in the past month. <br />Under -dispenser containment areas are free of water, debris, and hazardous substance. Sensors are located ro rl Y. <br />5a <br />- List all tank -top sumps, where alarms occurred in the past month: „�_ <br />Dispenser I / 2 Dispenser 9 / 10 <br />'Au-Ij L tom,�Ipy\ <br />Dispenser 3 / 4 Dispenser 11 / 12 <br />Note: Sumps where an alarm has occurred in the past month must be inspected unless a qualified service technician responded to, and <br />Dispenser 5 / 6 Dispenser 13 / 14 <br />properly addressed, the cause of the alarm. Attach documentation verifying appropriate service to this report. <br />Dispenser 7 / 8 Dispenser 15 / 16 <br />1 sump inspection is re wired, record results in item 6, below. <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 required 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 />Sum Location: h <br />Sump Location: <br />SuTp 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 I N I NA Y N NA <br />Tank 1 -Contents: jj &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 ro rl Y. <br />Y N I NA Y N NA <br />Dispenser I / 2 Dispenser 9 / 10 <br />Dispenser 3 / 4 Dispenser 11 / 12 <br />Dispenser 5 / 6 Dispenser 13 / 14 <br />Dispenser 7 / 8 Dispenser 15 / 16 <br />Notes 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 />