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I <br />Designated Underground Storage Tank (UST) Operator <br />Monthly Visual Inspection Checklist <br />I — T l il - 11M JNA - 11M J DDM""W <br />Item <br />Date: <br />Facility Add e55: <br />_6...'. " <br />Ci <br />Zi Z - <br />Designated UST Opeaior CO ductirt theoyv <br />Catification #' \ <br />Intermwrial Code Council 2 V <br />Ex'Piration Dare= 1-2 <br />Phone: 64Z I/. F 7-2 <br />I — T l il - 11M JNA - 11M J DDM""W <br />Item <br />MONITORING PANEL / ALARM HISTORY Y N <br />NA <br />_6...'. " <br />j'. <br />I <br />Monitor* system is p2veered an and in proper opea4anode_ <br />2 <br />Monitoring system isnot currently showing any alarms or Lings <br />3 <br />Alarm history reportAog for the previous month is available, and has been reviewed by the <br />Designated UST ator. ( trach a copy of The alarm hisfory report7og to this nrnz i m ailaule.J <br />4 <br />Each alarm for the previous month has been responded to appropriately <br />5 <br />Sensors looted intank-to p containment sumps have not alarmed � the anonth_.. <br />List all lank -top sumps where alarms occurred in the post month: <br />Nore. Sumps where an alarm has occurred in the pass month must be inspected unless a qualifled service technician responded ro, and <br />properly addressed, rhe cause ofthe alann. Attach documentation verifying OPProprOW S,*?'WCS 10 this report. <br />Ifs In item 6, below. <br />UST SYSTEM INSPECTION <br />6 <br />'rank -top contairtment sumps are free of water, debris, and hazardous substance. Sensors are located prupaly. <br />Now: VISIM2 ins Bct7oai o sum s is only required in sunt s where an alarm has o(xurred in the Past month forwhich there is no service record. <br />N <br />Sump Location: <br />Sump Location: <br />Y N- <br />SumpLocation <br />Sump Location: <br />r6eEt s+ SLmp Location: <br />Sum!R Location: <br />7 <br />Spill containment structures are free of water, debris,and hazardous substance. <br />I Y N NA I Y <br />NA <br />Tank F -Contents.'Ot,,L, Tank 3 - Contents: <br />Tank 2 -Contents: j,/ Tank 4 - Contents: <br />8 <br />Under -di spenser containment areas are free of water, debris, and hazardous substance Sensors are located woperly, <br />Y N NA I V N <br />NA <br />Dispenser I / 2 Dispenser 9 / 10 <br />Dis enser 3 /4 Dispenser 11112 <br />penser J3114 <br />Dis penser / 6 P.is <br />.5 -, <br />Dis enser 7/8 Dis enser <br />PAPERWORK INSPECTION Y N NA ,DA'T'E BONE <br />9 <br />MonitoringDLstemcertification has been completed within 12 months. <br />`/' <br />-To— <br />secondary containment tests have been earn feted within the rt-quired timeframe. <br />I I <br />Spill containment stractum (bucket) tesLWg was 2E�ijnleted within the past y=- 6-1 <br />-,12 V, <br />12 <br />Tank ti tress testing was Conn 2letedwithin required titridiame- 'X 1- <br />-13 <br />Line tightricss testing was copq1� <br />pleted within required tiwftme. <br />-T4-- <br />other required testis maintenance was completed within regiured tunefraine. {List test/maintenance items below.) <br />TestlMaintenance- <br />TesWaintenance: <br />TesWainfenance., <br />FACILITY EMPLOYEE TRAINING Y N <br />NA <br />15 <br />All facility employees have received the required on-the-job training within the past year. <br />lir <br />lity emplones hired within the past 30 days have received the EquirrA on -the -' training <br />Note. Any answer of "N" should be explained in the comment section on the t6now[ng page, anti Ymi require <br />follow-up action. <br />Page I of 2 <br />-Naim-nffier 2004 <br />H 'd 19H' ON WE-Ct6-60Z 'dMdi dICAd VN:6 0002 '9 'AN <br />