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C <br />Designated Underground Storage Tank (UST) Operator <br />Monthly Visual Inspection Checklist <br />Facility Name: —a <br />Date: 3-3/-05— <br />—3/—o5"Facili <br />Facility Address: <br />jV Of Applicame <br />City: <br />Zip Code: 7,1d <br />Designated UST Operator Conducting the Inspection: card /ria �r//e <br />International Code Council Certification #: 15 14 g 9 S g -UC— <br />Ex iration Date: <br />Si nature: <br />Phone: ,� o 4 fG, — <br />Item <br />■ — I CJ, 1\ = 1VO, INA <br />MONITORING PANEL / ALARM HISTORY <br />= <br />jV Of Applicame <br />Y <br />N <br />NA <br />1 <br />Monitor in s stem is owered on and in ro er operating mode. <br />2 <br />Monitoring system is not currently showing any alarms or warnings. <br />y <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/logreportllog to thisform i available.) <br />y <br />4 <br />Each alarm for the previous month has been responded to appropriately. <br />y <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 />!4sump inspection is re uired, record results in item 6, below. <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 o sun: s is only re uired in sun: s where an alarm has occurred in the past month or which there is no service record <br />Y N <br />Sum Location:n <br />Sump Location: <br />:! <br />''rR <br />N <br />Sum 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 N NA <br />N NA <br />Y <br />Tank 1 — Contents: �oy I <br />Tank 3 — Contents: <br />Tank 2 — Contents: I <br />Tank 4 — Contents: <br />8 <br />Under -dispenser containment areas are free of water, debris, <br />and hazardous substance. Sensors are located properly. <br />Y N NA N NA <br />Y <br />Dispenser 1/ 2 2 Dispenser 9 /10 <br />Dispenser 3 / 4 Dispenser 11 / 12 <br />Dispenser S / 6 Dis enser 13 / 14 <br />Dis enser 7 / 8 Dis enser 15116 <br />777 <br />PAPERWORK INSPECTION <br />Y <br />N 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 />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 />Page 1 of 2 November 2004 <br />