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C <br />Designated Underground Storage Tank (UST) Operator <br />Monthly Visual Inspection Checklist <br />Y = Yes. N = Na NA = Not APPR4 <br />Item <br />Name: c.&v rrg 19,eg E <br />Date: "R R 3 -OS <br />-Facility <br />Facility <br />Address: 7oj E CRA r L1 <br />5 z* r <br />zip code: s,-)oC_ <br />-City: <br />UST Operator Conducting the Inspection: /- A <br />- a Hr,wA <br />-Designated <br />International Code Council Certification #: 5047751 -tAC- <br />Expiration Date: 12 / /8 / -Loob <br />Si <br />Alarm history report/log for the previous month is available, and has been reviewed by the ✓ <br />Designated UST Operator. Attach a copy of the alarm history reportl7og report/7oto this form i available.) <br />Phone: 0?0 6o0 <br />Y = Yes. N = Na NA = Not APPR4 <br />Item <br />MONITORING PANEL / ALARM HISTORY <br />Y <br />N <br />NA <br />1 <br />Monitoring stem is powered on and in proper operating mode. <br />2 <br />Monitoring system is not currently showing any alarms or warnings. <br />3 <br />Alarm history report/log for the previous month is available, and has been reviewed by the ✓ <br />Designated UST Operator. Attach a copy of the alarm history reportl7og report/7oto this form i available.) <br />4 <br />Each alarm for the previous month has been responded to appropriately . <br />5 <br />Sensors located in tank -top containment sumps have not alarmed in the past month. <br />5a <br />_ 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 />!sumpIfsump inspection is required, record results in item 6. below. <br />UST SYSTEM INSPECTION <br />6 <br />Tank -top containment sumps are free of water, debris, and hazardous substance. Sensors are located properly. <br />Note: Visuul inspection ofsum s is only re nixed in stun xs where an alarm has occurred in the past month liar which there is no .semce record. <br />Y NY <br />N <br />Sump Location: UNC ✓ <br />Sump Locution: <br />Sump, Location: R " A / <br />Sump Location: <br />Sump Location: <br />Sump Location: <br />7 <br />Spill containment structures are free of water, debris, and <br />hazardous substance. <br />Y N NA <br />N NA <br />Y <br />Tank I - Contents: t_ L_, <br />Tank 3 - Contents: <br />Tank 2 - Contents: PRG'-rA( v M v7Tank <br />4 - Contents: <br />8 <br />Under -dispenser containment areas are free of water, debris, and hazardous substance. Sensors are located <br />ro erl . <br />Y N NA <br />Y <br />N <br />NA <br />Dispenser I / 2 Dispenser 9 / 10 <br />Dispenser 3 / 4 Dispenser I 1 / 12 <br />Dispenser S / 6 Dispenser 13 / 14 <br />Dispenser 7 / 8 1 1 Dispenser 15 / 16 <br />PAPERWORK INSPECTION N INA DATE DONE <br />Y <br />9 Monitoringsystem certification has been completed within t 12 months. 6-1-0 <br />10 Secondarycontainment tests have been completed within the required timeframe. ✓ 6- -0 <br />11 Spill containment structure (bucket)testingwas completed within the past year. - -0 <br />12 Tank tightness testin was con--- leted within required timeframe. ✓ 60-2-0 <br />13 Line tightness testingwas completed within required timeframe. to - - 0 <br />14 Other required testing/maintenance was co leted within required timeframe.(List testlmaiuunance items below. <br />TestlMaintenance: R <br />7 - -2 <br />TestlMaintenance: <br />Page I of 2 <br />November 2004 <br />