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[I <br />0 0 <br />Designated Underground Storage Tank (UST) Operator <br />Monthly Visual Inspection Checklist <br />Facility Na lay Date: <br />Facility Address: W <br />City: ICA I Zip Code: <br />Desipated UST Operator Conducting the Inspection: <br />International Code Council Certification #: Expiration Date: M) Z_ <br />Si2ature: UPLA!S� e"n LAA1 Phone: (S7'3() <br />,.RC) - <br />V - Yes, N = No, NA - Not Agplicable <br />Item 7_ MONITORING PANEL/ ALARM HISTORY Y I N I NA <br />I <br />Monitoring system is powered on and in proper 22erating mode. <br />2 <br />Monitoring system is not currently showing any alarms or warnings. <br />3 <br />- <br />Alarm history report/log for the previous month is available, and has been reviewed by the <br />Designated UST Orator. (Attach a copy ofthe alarm histo g LeEqllog to thisform ifavailable.) <br />4 <br />Each alarm for the previous month has been responded to appropriately. OE <br />5 <br />Sensors located in tank -top containment sumps have not alarmed in the past month. <br />5a <br />- List all tank -top surqps where alarms occurred in the past month: <br />1,1JA <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 />sump inspection is required, record results in item 6, below. <br />UST SYSTEM INSPECTION <br />Tank -top containment sumps, are free of water, debris, and hazardous substance. Sensors are located properly. <br />Note: Visual inspection of swmps is only requi in Sumps where an alarm has occurred in thepast month or which there is no service record. <br />Y N <br />Y N <br />Sump Location: <br />Sump 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 I NA Y N INA <br />Tank I - Contents: Tank 3 - Contents: <br />Tank 2 - Contents: Tank 4 - Contents: EIA <br />8 <br />Under -dispenser containment areas are free of water, debris, and hazardous substance. Sensors are located properly. <br />N _NA Y N NA <br />Dispenser I / 2 Dis enser 9 / 10 <br />Dispenser 3 / 4 Dispenser 11 / 12 <br />Dispenser 5 / 6 Dispenser.13 114 <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 I of 2 November 2004 <br />