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Designated Underground Storage Tank (UST) Operator <br />Monthly Visual Inspection Checklist <br />i~acili Name: <br />Date: <' <br />Facili ess: <br />2 <br />Ci <br />Zip <br />laesignat6d UST Operator Conducting the !Ls ion: <br />Alum history reportt'log for the previous month is available, and has been reviewed by the <br />International Code Council CpVfication : <br />e E ikradon Date: A !e <br />Sie: <br />Phone:( <br />Y = Yes, N —.Na. NA = Not �Llicablo <br />MONITORING PANEL / A Al2M $ISTOI2YNA <br />I <br />Monitoring system is Bred on and in plTer operating mode. <br />2 <br />Wilitozin ern is not currently shorvin&:4ny alarms or warnings - <br />3 <br />Alum history reportt'log for the previous month is available, and has been reviewed by the <br />Desi ed UST tor. (Attach a ca o the aiar»t history re rt/% to this orM i availa6le- <br />4 <br />Each alarm for ilat previous month has been )re nded to !pE2Eiately. <br />5 <br />Sensors loa=th in tank -top containment swaps have not alarmed in the past month - <br />5a <br />- ,List ,all tank -top sumps where alarms occurred in the past month: <br />!Vote: Sumps where ars alarm has occurred in the pasrmowh must be Inspected unless a qualified service techniciam rs+spohded to, and <br />properly addressed, the cause of the alarm Attach documenta#on verifying appropriate service to thls sport <br />sttm inspecffon is re ufred record results in Item F below. <br />UST SYS I'EM INSPECTION <br />6 <br />Tank -top containment sumps are free of water, debris, and hazardous substance- Scissors are located properly. <br />Notes threat ihs awlon ofstimps is On& required in sum s whsre an alarm has occurred in the aest month r which there is no service record. <br />Y <br />°u <br />jrk, <br />Y N <br />Sum !ovation, t <br />Sump Location: <br />;; .. <br />Sum Location: <br />Sum Location: <br />Salm Location:nmzcation: <br />SumoCatian_ <br />7 <br />Sill aontaient structures are free of water, debris <br />and i}azaraous <br />substance. <br />Y Ig NA Y N. <br />N.A. <br />'rank I ­ Contents: Tank 3 — Contents,- <br />'ontents,Tank <br />Tank2 — Contents.- Tania 4 — Contents: <br />8 <br />Under -dispenser containment areas are fire of water, debris, and hazardous substance. Sensors are located ro rl •- <br />Y N NA Y N <br />NA <br />Dispenser I /2 , Dr user 9 / 10 <br />Dir user 3 / 4 Dispenser 1.7 112 <br />Di user S/d L/ ,. ;�svenser 1,3114 <br />rispenser 7/8 Dianger 15 / 16 <br />PAPERWORK INSPECTION Y N NA 1 BATE DONE <br />9 Momitorin em certification has been cam, leted witlniu past 12 Month& <br />10 Secondary coamnment tests have been completed within the Muffed thneirame. <br />1l spill containwent stricture (bucket) testing was completed witlda the pLM yew. -r5 SC <br />12 Tank plAffiess testing was came feted m ithin required timeframe. �:::J <br />13 Lino tightness tc was completed within LeTEW t tmeframe. 1 3 .A4 _ v <br />14 Other PNMred to maintenance was coin letcci withinaired ti mL- mP. (List test/maintenance items below. <br />7estlMaintenance; <br />FA.CnJTY EWLOYEE TRAINING Y N INA <br />15 All facility to es have received the required on-the-jobwithin the past year, <br />I6 All. facility employees hired within the 30 stays have received the required on-the-job 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 />ZE 'd �9EZ'0N <br />Page 1 of 2 November 2004 <br />PN -06-6H 'dSNVL dlaAd PH:6 90H 'q 'ASW <br />