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Designated—UndergroundStorage Tank (UST) Operator <br />Monthly Visual Inspection Checklist <br />Facility Name: 9 d co <br />I Date: / - ,2 a 5 - <br />Facility Address: S S fi <br />N <br />Ci 4 &ck ttm <br />Zi Code: 9!� o5 <br />Designated UST Operator Conducting the Ins ection: <br />R1.4. d wa effe <br />International Code Council Certification #: s <br />Expiration Date: /2 <br />Signature: <br />Phone: ;to1 ) 4/66' Y65'S <br />Y = Yes. N = No. NA = Not Appbcable <br />Item <br />MONITORING PANEL / ALARM HISTORY <br />Y <br />N <br />NA <br />777 77,7 -, 777777 7777, <br />\ <br />1 <br />Monitoringsystem 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 report/logreportliog to this orm i available. J <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 sump inspection is re cored, record results in item 6 below. <br />?OEM _ <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 sum s is only re uired in sum s where an alarm has occurred in the past month or which there is no service record. <br />Y N <br />Sum Location: <br />4 ;' <br />F <br />N <br />Y <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 <br />hazardous substance. <br />Y N NA <br />N NA <br />Y <br />Tank 1 — Contents: e <br />Tank 3 — Contents: <br />Tank 2 — Contents: <br />Tank 4 — Contents: <br />8 <br />Under -dispenser containment areas are free of water, debris, <br />and hazardous substance. Sensors are located <br />properly. <br />Y N NA <br />Y <br />N NA <br />Dispenser I / 2 vi <br />Dispenser 9110_ <br />Dis enser 3 / 4 <br />Dispenser I L/ 12 <br />Dispenser 5 / 6 <br />Dispenser 13 / 14 <br />Dispenser 7 / 8 <br />Dis enser 1 S / 16 <br />_ - _ <br />,7 <br />PAPERWORK INSPECTION <br />Y <br />N <br />NA <br />DATE DONE <br />Monitoringsystem certification has been completed within past 12 months. <br />10 Secondarycontainment tests have been completed within the required timeframe. <br />I 1 Spill containment structure bucket testin was com leted within the past year. <br />F139 <br />12 Tank tightness testingwas completed within required timeframe. <br />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 <br />November 2004 <br />