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IN <br />Designated Underground Storage Tank (UST) Operator <br />Monthly Visual Inspection Checklist <br />Facility Name: <br />Date: <br />Facility Address: <br />Enammigam <br />Monitoring system is powered on and in proper operating mode. <br />City: <br />Zip Code: <br />Desi2ated UST Operator Conducting the Inspection: <br />Alarm history report/log for the previous month is available, and has been reviewed by the <br />Designated UST Operator. (Attach a copy of the alarm history reporillog to thisfiorm if available) <br />International Code Council Certification #: <br />Expiration Date: <br />Signature: <br />Phone: ( I <br />Y = Yes, N = No, NA = Not Applicable <br />Item <br />MONITORING PANEL / ALARM HISTORY Y N NA <br />I <br />Enammigam <br />Monitoring system is powered on and in proper operating mode. <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 />Designated UST Operator. (Attach a copy of the alarm history reporillog to thisfiorm 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 sumps have not alarmed in the past month. <br />5a <br />- List all tank -top sumps where alarms occurred in the past month: <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 />If'sug ins ection is e uired, record results in item 6, below. <br />4 <br />q g; '77 <br />—M R <br />pw 777,77,77 1'777777' T <br />UST SYSTEM INSPECTION <br />6 <br />Tank -top containment sumps are free of water, debris, and hazardous substance. Sensors are located properly. <br />Note: Visual inspection of'sum ps is only required in sumps where an alarm has occurred in the past month or which there is no service record. <br />Y N <br />Sump Location: <br />Sump Location: <br />Y NEt <br />Sum Location: <br />Sump Location: <br />6 <br />1 Sump Location: <br />Sump Location: <br />7 <br />Spill containment structures are free of water, debris, and hazardous substance. <br />Y N NA Y N NA <br />Tank 1 – Contents: 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 INA <br />Dispenser I / 2 Dispenser 9 / 10 <br />Dispenser 3 / 4 Dis' penser 11 12 <br />Dispenser 5 / 6 Dispenser 13 14 <br />Dispenser 7 / 8 gggser 15 116 <br />27 M:F,7777777 777,7-77, 77777177777777 <br />7,11-277" -717777m" , "" '" -� - � 7., .77.7 <br />772 7-7777 3171=7m�"',, <br />PAPERWORK INSPECTION Y N INA DATE DONE_ <br />9 Monitoring system certification has been completed within past 12 months. <br />10 Secondary containment tests have been completed within the required timeframe. <br />H Spill containment structure (bucket) testing was completed within the past year. <br />12 Tank tightness testing was completed within required timeframe. <br />13 Line tightness testing was completed within required timeframe. <br />14 Other required testing/maintenance was completed within required timeframe. (List test/maintenance items below) <br />Test/Maintenance: <br />Test/Maintenance: <br />Test/Maintenance: <br />i, MEN <br />FACILITY EMPLOYEE TRAINING Y N NA <br />,15 A�Ilfacility employees have received the required on-the-job training within the past year. <br />1 16 1 All facility employees hired within the past 30 days have received the required on-!he-'ob trainin . <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 <br />November 2004 <br />