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Designated Underground Storage Tank ('UST) Operator <br /> Monthly Visual Inspection Checklist <br /> Facility Mame: t RTLIROP SIS Y F0W mA-kU_ I Date: fr-rY O� <br /> FaciiirvAddress: t Awy I FAWAb£ Q, <br /> City: M 4 A1JT I Zip Code: 3 <br /> Desizatcd UST Operator Conducting the Inspection- 00. f_'AMNOicil <br /> internatiounc' S Expiration Date: <br /> Si_enunre:nal ode Co ! Phone: r 1 <br /> Y=YMIN Na NA=NotA ulimbie <br /> Item MONITORING PANELIALARM HISTORY Y N NAS <br /> I Monitoring system is powered on and in proper operating mode. <br /> 's 2 ! Monitoring system is not currently showing any alarms or warnmes. I <br /> , 3 ! .Alarm history repoMlog for the previous month is available,and has been reviewed by tine <br /> j Des' d UST Operator. (Attach a cogy ofhe alarm history re ort/lo to this jar-i 'available.) <br /> j 4 1 Each alarm for the previous mouth hasbeen responded to appropriately. a s <br /> 5 j Sensors located in tank-top containment sums have not alarmed in the past month. <br /> 5a - List all tank-top sumps where alarms occurred in the past month: <br /> j :Vote:Sumps where an alarm has attuned in the part month nisi be inspected uniem a quaftfied service technician responded to and <br /> _Property addressed. rhe:vuse of the alarm attach documentarian mrrfymg=provnaw service to tha report. <br /> (lS11mP:a5pectIDn fs:'e='d'record reMia in(tem 6.Oetow. <br /> UST SYSTEM INSPECTION 1 <br /> 6 Tank-top containment sumps are free of water,debris and hazardous substance. Sensors are located properly. <br /> .Vote: Yr.+va[insacco ai.xm.ms is only required in sumps wnete an alarm has occrned in the past month for which there a no mmur recom <br /> Y N j Y N <br /> Sum Location: 1 i Sump Location: <br /> Sump Location: `I Sump Location: <br /> Sump Location: i Sump Location: <br /> i Soill containment structures are free of water.debris,and hazardous substance. <br /> 1 i YA N INA1 Y1N NAj <br /> Tank 1 —Contents: I Tank 3—Contents: <br /> Tank 2—Contents: Tank 4—Contems: <br /> S Under di enser containment areas are fig of water,deons.and hazardous substance. Sensors are located properly. <br /> Y N INA , Y1 N I N <br /> Dispenser Iii 1VAI I I Dispenser 9110 <br /> Dispenser 3;-1 ! Drs eraser 11/12 <br /> Dispenser.i!o 1 Dispenser 13/14 <br /> ! Dtsoenser "S IV 1 1 Dispenser 15, lti <br /> PAPERWORK INSPECTION Y NA DATE DONE <br /> s 9 Monitoring sysrem certificarion has been completed within past 12 months. 2� <br /> 10 Secondary contaimnent tests have been completed within the required timeframe. I i oS <br /> 11 ! Spill containment structure(bucket)testing was completed within the ast year_ <br /> 12 ; Tank tightness testing was completed within required timeframe. I %/L 1 1 <br /> 13 Line tightness,testing was completed within required timeframe. f7) <br /> 1.1 Other required testingt maintenance was completed within rewired timeframe. rList test/maimenance items below) <br /> j Test/Matmenance: <br /> Test/,Maintenance: <br /> Test/Maintenance: I j <br /> FACILITY EMPLOYEE TRAINING Y N NA ; <br /> U faciliry empiovees have received the required on-the-job training within the past year. <br /> 6 All faciliry employees aired within the past 30 days have received the reouved on-the-job training. i ✓ <br /> Note: Any answer of"N"should be explained in the comment section on the roilowing page,and will require <br /> follow-up action. <br /> t <br /> Page I of: Senremner 200P <br />