Laserfiche WebLink
Designated Underground Storage Tank (UST) Operator <br />Monthly Visual Inspection Checklist <br />Facility Name: ® r <br />Date: <br />Facility Address: ,�, ,S" S -t <br />N <br />Y <br />City: <br />Zi Code: q 5-120 15- <br />Designated UST Operator Conducting the Inspection: <br />Sump Location: <br />International Code Council C fication #: 1(}$ $ $' U C- <br />Expiration Date: 2 / / �,O0 <br />Signature: <br />Phone: ;k ) GP <br />® — - Y = Yes, N = No, NA = Not Applicable <br />Item <br />MONITORING PANEL / ALARM HISTORYN <br />Y <br />N <br />Y <br />NA <br />Sum Location: <br />Sum Location: <br />Sump Location: <br />Sump Location: <br />77 <br />1 <br />Monitoring system is owered on and in proper operating mode. <br />Sump Location: <br />7 <br />2 <br />Monitoring system is not currently showing any alarms or warnings. <br />Y <br />N NA <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 report/logreporillog to thisform if available. <br />Tank 1 - Contents: Ore <br />Tank 3 - Contents: <br />4 <br />Each alarm for the previous month has been responded to appropriately. <br />4 - Contents.' <br />8 <br />Under -dispenser containment areas are free of <br />5 <br />Sensors located in tank -top containment sumps have not alarmed in the past month. <br />properl . <br />Y <br />5a <br />_ List all tank -top sumps where alarms occurred in the past month: <br />N NA <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 sum inspection is required, record results in item 6, below. <br />UST SYSTEM INSPECTION <br />Ink -top containment sumps are free of water, debris, and hazardous substance. Sensors are located properly. <br />Nim• vicunt inenectinn gf.cumns is only required in sumps where an alarm has occurred in the past month for which there is no service record <br />14 Other required testing/maintenance was completed within required timeframe. List test/maintenance items below. <br />Test/Maintenance: <br />Test/Maintenance: <br />Page 1 of 2 November 2004 <br />- - - Y N <br />N <br />Y <br />Sum Location: <br />Sum 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 <br />hazardous substance. <br />Y <br />N NA <br />N NA <br />Y <br />Tank 1 - Contents: Ore <br />Tank 3 - Contents: <br />Tank 2 - Contents: <br />H --Tank <br />4 - Contents.' <br />8 <br />Under -dispenser containment areas are free of <br />water, debris, <br />and hazardous substance. Sensors are located <br />properl . <br />Y <br />N NA <br />Y <br />N NA <br />Dis enser 1 / 2 <br />Dispenser 9110 <br />Dispenser 3 / 4 <br />Dispenser 11 / 12 <br />Dispenser 5 / 6 <br />Dispense 13 / 14 <br />Dispenser 7 / 8Dis <br />enser 15 / 16 <br /><•, <br />.. . . <br />77 7 <br />ION <br />PAPERWORK INSPECTION <br />N <br />Y <br />NA <br />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 />11 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 />Page 1 of 2 November 2004 <br />