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Designated Underground Storage Tank (UST) Operator <br />Monthly Visual Inspection Checklist <br />Facility Name $upeR e..&v7eR lyr - r Date: Jl�v 1 I C E <br />Facili Address:7c1 E CRA LAW <br />City: <br />CitycSr0Z* YON Zip Code: <br />Designated UST Operator Conducting the Inspection: Al A %ANa MYSLz,A <br />International Code Council Certification #: 50 4 7751 —Lk C— Expiration Date: /2 / !8 / L0 <br />Signature: Phone: o? O <br />Y=Yes,N= <br />Item MONITORING PANEL / ALARM HISTORY <br />1 Monitoring stem is powered on and in properoperating mode. <br />2 Monitoring system is not currently showing any alarms or warnings <br />3 Alarm history report/log for the previous month is available, and has been reviewed by the <br />Designated UST Operator. (Atlachacopyof the alarm history report/7oreportl7og to this form i available <br />4 Each alarm for the previous month has been responded to a propriately. <br />5 Sensors located in tank -top containment sum s have not alarmed in the past month. <br />5a - List all tank -top sumps where alarms occurred in the past month: <br />= Not Applicab <br />N I NA <br />Y <br />V� <br />Note: Sumps where an alarm has occurred in the past month must be inspected unless a qualified service technician responded ro, and <br />properly addressed the cause of the alarm. Attach documentation verifying appropriate service to this report. <br />lfsuTf ins ection is required, 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 ors+rm s is onh, re aired in sum s where an alarm has occurred in the past month for which there is .cervicNrecord. <br />Y N <br />Y <br />- z� Sum Location: <br />Sum Location: <br />Sum Location: - r � .� Sum Location: <br />Surtip Location: Sump Location: <br />7 Spill containment structures are free of water, debris, and hazardous substance. N NA <br />Y N NA <br />Y <br />Tank 1 — Contents: �_ t • - ✓ Tank 3 — Contents: <br />Tank 2 — Contents: P to F ✓ Tank 4 — Contents: <br />5 Under -dispenser containment areas are free of water, debris, and hazardous substance. Sensors are located rN erl l ,A <br />Y N NA <br />Y <br />Dispenser I / 2 1Z Dispenser 9 / 10 <br />Dispenser 3 / 4 <br />Dispenser 11 / 12 <br />Page 1 of 2 twvci,.. " <br />6 <br />Dis 5 / 6 <br />enser <br />Dispenser 15 / 16 <br />Dis ,ser 7 / <br />PAPERWORK INSPECTION <br />N NA DATE DONE <br />Y <br />__97 <br />Monitoring system certification has been com leted within past 12 months. <br />_ p <br />10 <br />Secon containment tests have been completed within the aired timeframe. <br />✓ _ <br />i ] <br />Sill containment structure (bucket) testing was completed within the past year. <br />GS <br />l2 <br />Tank ti tness testin was completed within required timeframe. <br />13 <br />7_77 - <br />Line ti tness testing was com leted within aired timeframe. <br />timeframe. (List <br />test/maintenance items below.) <br />14 <br />Other re aired testin maintenance was com leted within aired <br />Test/Maintenance: <br />Test/Maintenance: <br />Page 1 of 2 twvci,.. " <br />