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Desipat#Underground Storage T (US erator <br />Monthly Visual Inspection Checklist <br />Facili Name: �,, C .`.. �T 1 c <br />Date: P —(t', —e <br />Facility Address: 2,2_ ` <br />Y N <br />Ci!y: <br />Zip Code: <br />Designated UST Operatoi ConductiE& the Inspection: <br />Sump Location: <br />International Code Council Certification #: 1 '? ` -- U C1 <br />Ex iration Date: 1 O / / fie <br />Signature: l <br />Phone: (-r-30) Cc IRO --- 2-9 Ess S" <br />W, <br />-MONITORINGEM ALARM HISTORY <br />��. <br />I <br />Monitorin system is p2wered on and in proper operatiLig operatingmode. <br />Y N <br />Y N <br />2 <br />Monitoring system is not currently showing any alarms or warnings. <br />Sump Location: <br />Sump Location: <br />Sump Location: <br />3 <br />Alarm history report/log for the previous month is available, and has been reviewed by the <br />Desi ted UST Operator. Attach a co of the alarm history report/logrepon4og to theaorm i available. <br />7 <br />Spill containment structures are free of water, debris, and hazardous substance. <br />4 <br />Each alarm for the previous month has been responded to appropriately. <br />Tank 1 - Contents: vv,.. Tank 3 - Contents: <br />Tank 2 - Contents: Tank 4 - Contents: <br />5 <br />Sensors located in tank -top containment sumps have not alarmed in the past month. <br />Y N NA Y I N I NA <br />5a <br />_ List all tank -top sumps where alarms occurred in the past month: , "f T ,^ j" tJ <br />Dispenser 3 / 4 Dia sneer 11112 <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 />1 sump inspection is required, record results in item 6, below. <br />f INSPECTION <br />6 <br />Tank -top containment sumps are free of water, debris, and hazardous substance. Sensors are located properly. <br />-104'Note: Visual insction of stamps is only required in sums where an alarm has occurred in the past month for which there is no service record. <br />Y N <br />Y N <br />Sum Location: i.�( <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 I N I NA Y N NA <br />Tank 1 - Contents: vv,.. 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 I N I NA <br />Dispenser 1 / 2 Dispenser 9110 <br />Dispenser 3 / 4 Dia sneer 11112 <br />Dis sneer 516 Dis enser 13 114 <br />Dispenser 7 / 8 Dispenser 15 / 16 <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 />