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<br />Facility 7a -m :
<br />0 41
<br />Designated Underground Storage Tank (UST) Operator
<br />Monthly Visual inspection Cbecklist
<br />. r rI Date_ -V —/ 49
<br />5
<br />1JC5l !UUC;U UJ J V u�va .............,..... .... -
<br />XrtterMtiorW Code Council CerFification #; 5, - 0
<br />JEXPirationbate. / 1 r V l.'t
<br />Phone: ( '
<br />Si
<br />tie: r z.
<br />Y=YmN-No i1"A=NotA
<br />]tcab
<br />MONITORING PANEL /ALARM SISTORY
<br />Item
<br />' 9-L`•,.
<br />a
<br />.•'"11 irv.,,,"'1'A :, ': L. l.!• 'w,. 7..•,,h.rt ti.li ., i ,:.iv h'.+,i 1. .. V,. �,: 4ir .fal
<br />1
<br />Monitorixtg system is veered on and in ro r o ratio made -
<br />2
<br />Monitarin em is not ctyrrend sbowizt an alarms or warnitt s-
<br />3
<br />Alarm history repvrtJlog fflr the previous maztth is available, and en reviewed by tVc
<br />Desi ted UST star, Attach a co y o the alarm histo re rUlo to this arm if availablej
<br />4
<br />Each alarm for the previous mouth has been responded to aPPTT, )Y•
<br />5
<br />Sensorslootedin tank -to 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 />Nota: Sumps where an Marra has occurred in the past month trrust be inspat,4ed -Uss a qualified sertice technhFian responded to, and
<br />properly addressed the cause of the alarm. Attach documentation verifying appropriate service to this report.
<br />-
<br />elow
<br />Itsump ins action is reqWY0 record resuUs in item 6 below-
<br />UST SYSTEM INSPEMON
<br />UST
<br />6
<br />Task -top containment sumps are free of water, debris, and hazardous substance- Sensors are locatod propcdy'•
<br />Nara: �i371R! ias ceori o sum s is oral na uir ed to su s where an alarm has occurred to the past month or s<`hiah there is no service record
<br />Y N
<br />- -
<br />Y N
<br />4 w
<br />,Sum Location:
<br />��:y3
<br />$um Location.
<br />�s
<br />Sump Location;
<br />; '
<br />Sura Creation:
<br />.sum Location:
<br />,�1�4+d�3,?'
<br />Sum Location:
<br />e?��'�,
<br />7
<br />Spill co=dment structures are free of water debris, and
<br />hazardous substance.
<br />- Y N NA
<br />Y N
<br />NA
<br />Tank 1 - Contents:11 t,
<br />Ox u
<br />Taalt 3 - Contents.
<br />Tank 2 a Canrents:
<br />Tank 4 - Contents:
<br />$
<br />Under -cit neer comment areas are tree of water, debris,
<br />and hazardous substance. Sensors are loeatecl properly.
<br />Y N NA Y N
<br />NA
<br />Lis user 1 /2 9 / JO ----------
<br />B�Dispenser
<br />Dispenser 3 / 4 Dis enser 11 i 12
<br />Dis eraser 5 / 6 Dis eraser 1311 d
<br />Dispenser 7.18 Di user 1 l 16
<br />S
<br />.r.' -.sr
<br />a gra xcx..^a: , .R., �: ,.'!✓,E"�,tn,: ra�s,.:r n+ ,. �.w'r;��v^�,, ,,,:4. � ; ki,� ,:a.rs:,.ary
<br />N NA DATE DONE
<br />PAPERWORK INSPECTION Y'
<br />9
<br />Monitorin tens cert cation has leen completed within Past 12 Months.
<br />10
<br />Secondary contaimmnt tests have been G feted within the r ' tirneft'axrte-
<br />11
<br />S ill containment structure Licket} teqLnZ was completed within the ytar-
<br />12
<br />Tank tightaess tesrin was co feted within r - cd timeframe.
<br />13
<br />Line tightness - vvas cont feted within r uired tinidiame-
<br />.
<br />14
<br />Other req=ed testing/maintenance was completed wvitltin ed timeframe.(List test/maintenance items below.)
<br />TesVMaintenance:
<br />Test/Maintenance:
<br />Tee aintenance:
<br />15 All facie em 1
<br />16 All facili emp]
<br />ote: Any answer of"
<br />follow-up action.
<br />V£ 'd 99£�'0N
<br />��, - ,, LIT..,: - -- - .:., .......
<br />FACIY E ..
<br />W'LOYiEE TRAINING Y I N I NA
<br />received the MLIon-the-'ob iraa►in within the past car.
<br />t witbin the past 30 days have received the uired on-the--ob
<br />be ex}rWaed in the comment: section On the f®llOwlrtg page, and will require
<br />Page l of 2 November 2004
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