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C <br />Designated Underground Storage Tank (UST) Operator <br />Monthly Visual Insnection Checklist <br />Facility Name: C-OV7 <br />Date: 40 N 6 <br />Faci I ity Address: ' c E CNA r <br />N <br />City: Glc r <br />Zip code: S a (o <br />Designated UST Operator Conductin the Inspection: /- A <br />'> HflwA <br />International Code Council Certification #: Sn7 4 7 i 51 - u C- <br />Ex iration Date: / 2 / /9 / 1006 <br />Signature: <br />Phone: o? O 0o o v <br />v V_ N = N.. NA - Nnt Annlir.hle <br />Item <br />MONITORING PANEL / ALARM HISTORY <br />Y <br />N <br />NA <br />Monitoringstem is powered on and in properoperating mode. <br />2 <br />Monitoringsystem is not currentlyshowinganalarms or warnings. <br />3 <br />F41 <br />Alarm history report/log for the previous month is available, and has been reviewed by the <br />Designated UST Operator. Attach a co o the alarm histo re ort/lo to thisform i available.) <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 />ifsump 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 o%sums is only reyid in sums where an alarm has occurred in the post monih /br which there is no .service record. <br />Y N <br />N <br />Y <br />Sump Location: Lloal,-rli <br />Sump Location: <br />Sump Location: &o•,k oo-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 1 -Contents: -A ,/ <br />Tank 3 - Contents: <br />8 <br />Tank 2 - Contents: Tank 4 - Contents: <br />Un--dr—dispenser containment areas are free of water, debris, and hazardous substance. Sensors are located Droperl . <br />Y N NA N NA <br />Y <br />Dispenser 1 / 2 <br />Dispenser 9110 <br />Dispenser 3 / 4 <br />Dis eraser 11 / 12 <br />Dispenser 5 / 6 <br />Dis enser 13 / 14 <br />Dis user 7 / 8 <br />Dispenser 15 / 16 <br />PAPERWORK INSPECTION N NA DATE DONE <br />Y <br />9 Monitoring system certification has been conMleted within past 12 months. <br />10 Secondary containment tests have been completed within the required timeframe. - — <br />11 Spill containment structure(bucket) testin was completed within the past year. G - — o <br />12 Tank tightness testing was completed within required timeframe. - - ° <br />13 Line tightness testing was completed within required timeframe. 6-A-0 <br />14 Other required testing/maintenance was completed within required timeframe. isl test/maintenance items below.) <br />TestlMaintenance: <br />TesdMaintenance: <br />Page 1 of 2 <br />November 2004 <br />