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<br />Designated Underground Storage Tank (UST) Operator
<br />Monthly Visual Inspection Checklist
<br />Facility Name, Date: J
<br />Facility Address: r
<br />Ci ; Zip Code: fl
<br />Desi d UST erator Conduetin the In ection_
<br />ternational Cade Counczl CemtifiCation #: Expiration Date:
<br />Si afire: �` ► Phoiie. ( )
<br />Y-Yes,N-No,NA.'-YotA �
<br />I
<br />tem MONITORING PANE, / ALARM ITSTO�tY Y N N.
<br />m is veered on and in ro m is bot ctrrrerrtl h )win an alarms or warnitigS,omtllog for the previous month is available, and bas been meviewed by the
<br />Desi ted UST Operator. (Attach a eo o the alarm histo re rt4o to this orm i available, v°
<br />4 Each alaun for thepi-mous ruouth has been responded to appropdately, b�
<br />5 Sensors Pocated in tank -to containment sunq5s have not alarmed in the past rnonth. �
<br />5a List all tank-toga sumps where alarms occurred in the past month.-
<br />Note: Sumps 'where an alarm has oocurrsd in the pas? month must be inspected unless a qualified service technician responded to, and
<br />properly addressed, the cause Of the alarm, Attach appropriate service to this report.
<br />I sura in pen is r4 aired, record resxks in item 6, balaw.
<br />.: •,': AI k .IN', :.,�j ,1+1 M1,��n ..V. L -i', I.Mr,l': .'aj:. T, '{,
<br />p sum}�s are free of�water� debris, ami hazard©us Substance. Sensors ata IoCated
<br />ON
<br />6 Tanlz ro Coma,r�mPnr properly.
<br />NOte: Visual ins etian o sem s is oral re aired in sum s wf�ere a� alarm has occurred to the est month ar �vhlch there 1s rte servic��yrecord
<br />IVSi
<br />("f"r Y ?
<br />Sum Location rt SumpLocxlon: i
<br />Sum .location: S ' ,� Sum Location: f
<br />Sum Location:Sum Location:
<br />is
<br />7 S contaicunent Structures are free of water debris, and hazardous substance.
<br />Y N NA v N NA
<br />Tants 1— Contents: M tr, t? , y/ . Tank 3 — Contents:
<br />Tank 2 — Contents Taaals 4 — Contents.
<br />8 Under ' nser containment areas are free of water, debris, and hazardous substance, Sensors are located properly.
<br />Y N NA, YJ N NA
<br />1)is eraser 1 f 2 Dispenser 9 / 10
<br />Dispenser 3 / 4 Dispenser 11 / 12
<br />Dispenser 5 / 6 Dispenser 13 / 1 G
<br />Dispenser 718
<br />Dis enser 15 / 16
<br />.. ,. 3§1,..s .u.. $S;i.�,:tb,..d(t 4 e1'::•:M r.!Bw,.. ",9,I, :,r,-.,,. m e'"r�4n Ri. ,.i I., it
<br />PAPEftWO)ESPECzON Y N NA DATE DONE
<br />9 Monate p system certification has been completed withni st 12 months.
<br />10 Secondary containment tests have been completed within the r uired timeframe. r
<br />11 Sill containment structure ticket testin was con letcd within the st ear.
<br />12 Tank tightness t -vas con feted within required t meframe. —.X y _Lye)
<br />13 Line nim mess --I-- completed within re ed timeframe.
<br />14 Other r aired ---- mafi tenarice was completed withinr aired timeframe, first test/maintenance items below.)
<br />Test/Maintenance:
<br />Test/Maintenance:
<br />Test/Maintenanoe:
<br />r rrtl ': y;:;r. r?'.Rt �W=lksir,. ':fs'Jo-: f tui �fddt a,',9 etb,..d"9: o'�k`, K� �'aur;fq•,AeerJs71'yl�^,c
<br />W.. r,.fir5'
<br />_ j.�'rf
<br />FACILITY E1"LOYEE TvAraNG Y N N.A.
<br />15 All facih employees have received the required on-the-job training within the past year_
<br />16 All facility eta la ees hired 'within the past 30 Pis have received the re aired on--die-job training_
<br />Note: Any answer of °SIV" should be e�lained in+ the comment section► on the following page, and will require
<br />follow-up action.
<br />Page 1 of 2 November 2004
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