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C <br />Designated Underground Storage Tank (UST) Operator <br />xAnnthly Vicnnl Incnertinn Checklist <br />---i -J . __ --- --r - - <br />Facility Name: 5'upeg CE'iv Tee t9AR r <br />Date: - e% ( - O <br />Facility Address: '%1 E' C RAR r6A <br />N <br />city: Uc r <br />Zi Code:7!7,4 0 6 <br />Designated UST Operator Conductin the Inspection: /- A <br />- 4PV-OA <br />International Code Council Certification #: $d 4 i i 51 - 4A L <br />Ex iration Date: /1 / / 8 / ioo(, <br />Si ature: <br />Phone: o?O coo <br />Y = Yes. N = No. NA =Not Applicable <br />Page 1 of 2 Novemuer IUU4 <br />MONITORING PANEL / ALARM HISTORY <br />N <br />NA <br />Item <br />Y <br />1 <br />Monitoring tem is 22wered 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 report/logreportfiog to this orm if 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 />Sa <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 />Ifsump inspection is required, record results in item 6. below. <br />UST SYSTEM INSPECTION <br />6 <br />Tank -top contai*ment sumps are free of water, debris, and hazardous substance. Sensors are located properly. <br />Note: Visual inspeclion ofsrim s is only re uired in s•umgav where an alarm has occurred in the st month or which (here is no service record. <br />Y N N <br />Y <br />Sum Location: tA0.) - ✓ Sum Location: <br />Sum Location: A � Sum Location: <br />Sum Location: Sum 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 1 - Contents: Uw f <br />Tank 3 - Contents: <br />Tank 2 - Contents: QC -4v %M Tank 4 -Contents: <br />Under containment areas are free of water, debris, and hazardous substance. Sensors are located <br />rN erl <br />8 <br />-dispenser <br />NA <br />Y N NA <br />Y <br />Dispenser I / 2 <br />Dispenser 9 /10 <br />Dispenser 3 / 4 <br />Dispenser 11 / 12 <br />Dispenser 5 / 6 <br />Dispenser 13 114 <br />Dis er 718 <br />Dis enser 15 / 16 <br />PAPERWORK INSPECTION <br />N NA DATE DONE <br />Y <br />Monitonn system certification has been completed within t 12 months. <br />-o <br />i�, <br />Secondarycontainment tests have been completed within the required timefiarne• <br />-2'-0 <br />Spill containment structure (bucket)testin was corn leted within the past year. <br />F'� <br />;E <br />-0 <br />Tank tightness testis was completed within required timeframe. <br />' 2 ' ° <br />Line ti tness testis was corn leted within uired timeframe. -7 -O <br />items below. <br />14 Other required testis maintenance was completed within required timeframe.(List tesemaintenance <br />Test/Maintenance: L -v A <br />TestlMaintenance: <br />Page 1 of 2 Novemuer IUU4 <br />