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Designated Underground Storage Tank (UST) Operator <br />Mnnthly Vicnal Inspection Checklist <br />Item <br />Date: v &j- O - <br />FacilityName: u CFiv T <br />N <br />Facility Address: lei E' ChHA R - li%a <br />City: S Glc r <br />Zi code: 5 a C� <br />Designated UST Operator Conductin the Inspection: A A <br />- Z- Ph -x -A <br />International Code Council Certification #: 50?4 7751 -1.1G <br />Expiration Date: /I// g / .1001, <br />Si afore: <br />Phone: o?O .1000 <br />v — "_ N = Nn NA = Nnt Annlicahle <br />Item <br />MONITORING PANEL / ALARM HISTORY <br />N <br />NA <br />Y <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 =available.) <br />Designated UST Operator. Attach a co o the alarm histo re ortl7o form4 <br />Each alarm for the revious month has been res nded to a ro riatel . <br />5 <br />Sensors located in tank -to containment sum s have not alarmed in the a <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 addresse4 the cause of the alarm. Attach documentation verifying appropriate service to this report. <br />If sump 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: Visual inspection ofsnm s is onh, re uired in snm s where an alarm has occurred in the past month for which there is no service record. <br />Y N N <br />Y <br />Sump Location: LA"Lc rG-n Sump Location: <br />Sum Location: Sump Location: <br />Sump Location: 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 1 - Contents: c -D ,/ <br />Tank 3 - Contents: <br />Tank 2 - Contents: PRF,U k 0 &-, Tank 4 - Contents: <br />8 <br />Under -dispenser containment areas are free of water, debris, and hazardous substance. Sensors are located ro erl . <br />Y N NA N NA <br />Y <br />Dispense I / 2 <br />Dispenser 9110 <br />Dispenser 3 / 4 <br />Dispenser I 1 / 12 <br />Dispenser 5 / 6 <br />Dispenser 13 / 14 <br />Dispenser 2 / 8 <br />Dispenser 15 / 16 <br />PAPERWORK INSPECTION N NA DATE DONE <br />Y <br />9 Monitoring system certification has been completed within past 12 months. 6 - 3 - o <br />10 Secondary containment tests have been completed within the required timeframe. - - <br />S ill containment structure ucket testin was co leted within the ast ear.Tank <br />titness testin was com leted within uired timeframe.Line <br />tightness testingwas completed within required timeframe. <br />F13 <br />Other required testing/maintenance was completed within required timeframe. List test/maintenance items below. <br />Test/Maintenance: <br />Test/Maintenance: <br />Page 1 of 2 November 2W4 <br />