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Designated Underground Storage Tank (UST) Operator <br />Monthly Visual inspection Checklist <br />Facility Name: C.&vr <br />Date: Mow -16 - CS <br />Facility Address: 7o I E CRA r Wa <br />Spill containment structure(bucket) testing was completed within the past year. <br />City: �$ -01YZi <br />Code: 7Soho 6 <br />Designated UST Operator C nducting the Inspection: i1 <br />- a IfP.A <br />International Code Council Certification #: 5o 47751 -LAC- <br />Expiration Date: /2 <br />r�Signafore: <br />Phone: c? O do 00 <br />v — Vo. N — Nn NA=Nn. An H—ble <br />Item I MONITORING PANEL / ALARM HISTORY <br />Y <br />N I NA <br />1 Monitoring stem is powered on and in.pruper operating mode. <br />2 Monitoring system is not currently showing any alarms or warnings. <br />3 Alarm history reportilog for the previous month is available, and has been reviewed by the <br />Designated UST Operator. Attach a copy o the alarm histo report/7oreportl7og to thisform if available.) <br />.4 Each alarm for the previous month has been responded to appropriately. <br />5 Sensors located in tank -top containment sumps have not alarmed in the p ast 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 />property addressed the cause of the alarm. Attach documentation verifying appropriate service to this report. <br />i .sum inspection is re uired 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 ofstim s is' only re uired ' sum as where an alarm has occurred in the East month or which there is no service record. <br />Y I N I N <br />Y <br />Sump Location: W"�_ C) sump Location: <br />Sump Location: Mm lviA Sump Location: <br />Sump Location: Sump Location: <br />7 Spill containment structures are free of water, debris, and hazardous substance. <br />Y I N I NA N NA <br />Y <br />Tank 1 -Contents: t ljjtzo M Tank 3 - Contents: <br />Tank 2 -Contents: v.0 Tank 4 - Contents: <br />8 Under -di nser containment areas are free of water, debris, and hazardous substance, Sensors are located roeel . <br />Y N NA N <br />Ty N A <br />112 Dis eraser 9 /10 <br />3 / 4Dis eraser 11112 <br />5/6 Di nserl3/14 <br />718 i/ Dis enser 15 / 16 <br />PAPERWORK INSPECTION N I NA I DATE DONE <br />Y <br />.... - _.�_ I.'/_I I I r -t - ocs <br />9 <br />10 <br />Morutonng system cenrncauon nas otxn cot,t ic—u w.u.... ...-•�•- •�• <br />Secondary containment tests have been completed within the required timeframe. - - <br />H <br />Spill containment structure(bucket) testing was completed within the past year. <br />12 <br />Tank tightness testing was completed within <br />required timeframe. <br />13 <br />Line ti tress testis was completed within <br />required timeframe. <br />-2_--o'4 <br />List items below. <br />14Other <br />required testis maintenance was completed <br />within required timeframe. <br />test/maintenance <br />Test/Maintenance: is V A <br />Y--- o S <br />Test/Maintenance: Rte PLAe-� <br />NczzcL- tv- <br />— - ° <br />Page I of 2 November Ltxr4 <br />