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Designated Underground Storage Tank (UST) Operator <br /> i/iontbly Visual Inspection Checklist <br /> Facility yams: E 41 a f- <br /> i Dare' .;.3-457 <br /> Facutry .address. lqytorj tAyr/ t <br /> City: Zip Code: <br /> Desieaated UST Operator Conducting the Inspecdon: tiy� <br /> lntemarionai Fade CoWjl Certification : —U C, I Expiration fDaw. / p� <br /> i Siwatnre: 1 Phone:( Zp^ ) p -1y6 S <br /> Y—Yea N=No.NA=Not-Anti i©bie <br /> Item MONITORING PANEL/ALARM HISTORY Y iN NA <br /> -- _ <br /> Momwnn system is powered on and in proper operating mode. <br /> Mmatoring system is not currently showing any alarms or warnines, <br /> alar history report4og for the previous month is available,and has been reviewed by the <br /> Designated UST Operator. (Attach a co , of the alarm history report1log report/logto this form i 'available.} <br /> 4 i Each alarm for the previous month has been responded to atel . #0 A An.* <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 /> i <br /> j ! :Vote:Sumps where an alarm hat occurred in the past month mutt he inspected uniem a quaiiijkd service tectmician responded to,and <br /> ;7roveriv o ssed the of the atarm jaarhdononentanon verifymg am opmate w,,ce m this report. 3 <br /> if sumo,mvf tion u reamred,mccrd results in item 6.below. I <br /> UST SYSTEM INSPECTION f <br /> b Tank-top containment sumps are free of water,debris,and hadons substance. Sensors are located properly. i <br /> Yore: %isuat insmemon of s turns is oniv rerpumd in sumps where an alarm pas occarred in the parr month for-. hmch there is no LE recora <br /> YY t 7 1 Y N <br /> Sump Location: Sump Location I <br /> Sump Location: Sump Location: <br /> m Location: <br /> Sump Location: <br /> Su1 <br /> 1 ' ! Soill containment structures are time of water,debris,and hazardous substance. <br /> Y N I NA j -- - Y�N NA i <br /> Tank 1 -Contents: Tank 3-Contents: i <br /> 1 Tank 2-Contents - �7 1 Tank 3-Contents: i I <br /> S Under-dispenser containment areas are tie-of water,dermis.and hazardous substance. Sensors are located properiy. 3 <br /> Y ! N NA Y N I NA <br /> Dispenser 1/Z I Dispenser 9 i 10 <br /> Dispenser 3 j Dispenser 11,'12 <br /> Disvenser 6 Dispenser 13,14 f <br /> i Dispenser ' Y ! Dispenser 15, 16 I <br /> PAPERWORK INSPECTION Y Y 1 NA DATE DONE <br /> 9 Monitoringsystem certification bas been completed within past 12 months. y -o <br /> 10 Secondary containment tests have been completed within therequired timeframe. ; _p <br /> 11 Spill containment structure(bucket)testing was completed within the past vear. I V I �ro <br /> 12 ; Tank rightness testing was completed within required timeframe. 1 <br /> 3 13 Line tightness testing was completed within required timeframe <br /> 14 1 Other required iestingimaintenance was completed within rewired timeframe. (List testhnaimenance items oefow.i <br /> Test Maintenance: <br /> Test/itlamtenance: <br /> { 1 TestIMaintenance: <br /> FACILPTY EMPLOYEE TRAINING Y x N NA <br /> All tactitty employees have received the required on-the-job training within the past year. <br /> 6 All racilit eemployees hired within the past 30 days have received the rewired on-the-'obtminint <br /> Note: Any answer of"N" should be explained in the comment section on the following page, and will require <br /> follow-up action. <br /> t <br /> Page 1 of 2 September JOS <br />