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Aff®rda- N$$t 'j <br /> 800 <br /> operator <br /> 800 524-9087 FAX 209 794-0112 Monthly Inspection Checklist <br /> Facility Name: ;. t Ur,r }. Date: <br /> Facility Address: 4Gi 5 A ,� <br /> Ci : r Y1 � -� Zi Code: <br /> Designated UST Operator Conducting the Ins ction: L 1 , r <br /> International Code Council Certification#: "� . Expiration Date: *- /oa /0 <br /> Si nature: Phone: Ae <br /> r1q •- 13 <br /> Y Yes,N—No.NA o Not Appikable <br /> Item MONITORING PANEL,/ALARM HISTORY N NA <br /> Y <br /> I ing system is powered on and in proper operating mode. <br /> 2 Monitoring stem is not currently showing any alarms or warnings. <br /> 3 Alarm history report/log for the previous month is available,and has been reviewed by the <br /> Designated UST Operator. Attach a c!?py o the alarm histo re ortllo to thisform i available.) <br /> 4 Each alarm for the previous month has been responded to a2propriately. <br /> 5 Sensors located in tank-top containment sumps have not alarmed in the past month. <br /> 5a - 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 /> !srrm ins eetion is required record results in item 6,below. <br /> UST SYSTEM INSPECTION <br /> 6 Tank-top containment sumps are free of water,debris,and hazardous substance. Sensors are located properly. <br /> Nate.-Visual inspection o sum s is only requi in sumps where an alarm has occurred in the past month or which there is no service record. <br /> Y N N� ,. <br /> *idc <br /> Sump Location: Y' ti`5r Sump Location: <br /> Sump Location: .` Sump Location: <br /> Sump Location: rr�.,,&": Sump Location: <br /> 7 Spill containment structures are free of water,debris,and hazardous substance. <br /> Y N NA N NA <br /> Y <br /> Tank 1—Contents: F- {` "' Tank 3—Contents: <br /> Tank 2—Contents: ;` �` Tank 4—Contents: <br /> 8 Under-dispenser containment areas are free of water,debris,and hazardous substance. Sensors are located properly. <br /> Y N NA N NA <br /> Y <br /> Dis enser!/2 1 Dispenser 9110 <br /> _Dispenser 3/4 Dis user 11/12 <br /> Dispenser 5/6 Dispenser 13/14 <br /> Dispenser 7/8 Dispenser 15/16 <br /> PAPERWORK INSPECTION N NA DATE DONE <br /> Y <br /> 9 Monitoring system certification has been completed withinpast 12 months. <br /> 10 Secondary containment tests have been completed within therequired timeframe. ^� <br /> i 1 Spill containment structure(bucket)testing was completed within the past year. <br /> 12 Tank tightness testing was completed within required timeframe. <br /> 13 Line tightness testing was completed within required timeframe. <br /> 14 Other required testis maintenance was completed within required timeframe. aist test/maintenance items below. <br /> Test/Maintenance.• <br /> Test/Maintenance: <br />