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Designated Underground Storage Tank (UST) Operator <br />Monthly Visual Inspection Checklist <br />T, Facili Name: c&vT <br />jD.1 i t o 5 <br />FIcil1 Address: %1 E CHA r GvA <br />Ci �$ Y :0�0Desi ted UST rator Conductin the Ins ection: Aa rfr4,uAIntemational Code Council Certification#: Sa' F7951 - to L n Date: 12 / 8 / Zoo6 <br />Phone: o?O t'000 <br />Signature: Y = Yes, N = No. NA = Not Applicable <br />Item <br />MONITORING PANEL / ALARM HISTORY Y N NA <br />1 Monitorin system is powered on and in proper operating mode. <br />2 Monitorin -v-tem is not currentl showin an alarms or wamin s. / <br />3 Alarm history report/log for the previous month is available, and has been reviewed by the <br />Desi aled UST operator. Attach a co o the alarm histo repo' <br />to this orm i available. <br />4 Each alarm for the previous month has been re onded to a ro riatel . <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 Q qualified ice to this report.ervice technician <br />responded to, and <br />properly addressed, the cause of the alarm. Attach documentation verifyingapp p <br />/ sum ins ection is re aired, 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 />Note: Visual inspection o .cum s is onh, re aired in slim s where an alarm has occurred in the past month for which there is no servicNrecord. <br />Y N h <br />Sum Location: <br />Sum Location: c�1.NLCAt�� Sum Location: <br />Sum Location: PRC�ty Sum Location: <br />Sum Location: <br />7 S ill containment structures are free of water, debris, <br />ris, anAd hazardous substance. N NA <br />Y <br />Tank 1 - Contents: LA- + r Tank 3 - Contents: <br />Tank 2 -Contents: PR&-r­ wr^ <br />Tank 4 - Contents: <br />8 Under-dis enser containment areas are free f water, ldeebris, and hazardous substance. Sensors are located rN er NA <br />Y <br />Dis enser 1/ 2 Dis enser 9 / 10 <br />Dis enser 3 / 4 Dis enser 11 / 12 <br />Dis enser 5 / 6 Dis enser 13 / 14 <br />Dis enser 7 / 8 Dis enser 15 / 16 <br />PAPERWORK INSPECTION I I- Y N NA DATE DONE <br />6- -o <br />9 Monitorin s stem certification has been completed within past 12 months. _ -0 <br />10 Secondarycontainment tests have been completed within the r uired timeframe. -0 <br />11 S ill containment structure(bucket) testing was completed within the past year. <br />12 Tank ti htnf--q- testing was com leted within re aired timeframe. 6_2 _ a <br />13 Line ti mess testing was completed within required timeframe. <br />14 Other required testin maintenance was completed within requim eframe.(List test/maintenance items below.2. <br />TesilMaintenance: 1: V'g <br />Test/Maintenance: <br />Page 1 of 2 November 2004 <br />