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Designated Underground Storage Tank (UST) Operator <br />� . _+ ti_. v:.....t T..o.,uM• f%rn C..hPV.klist <br />Item <br />MONITORING PANEL I ALARM HISTORY <br />Y <br />N I NA <br />1 Monitorin cvqtem is powered on and in—roper opem4ng mode. V <br />s <br />2 Monitorin stem is not currentl showin an alarrns or wamtn s. <br />3 Alarm history repoMog for the previous month is available, and has been reviewed by the <br />Desi ated UST rator. Attach a co o the alarm histo re rtRo to this arm i available. <br />4 Each alarm for the previous month has been res nded to appropriately. <br />5 Sensors located in tank -to containment sum have not alarmed in the pas month. ✓ <br />5a - 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 he 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 />/r n.mn insnvcaon is required record resulu in item 6, below. <br />UST SYSTEM INSFUC I WN <br />6 Tank -top containment sumps are free of water, debris, and hazardous substance. Sensors are located properly. <br />Note: Visual inspection o slim s is only re aired in sum s where an alarm has occurred in the past month for which there is no service record. <br />Y N Y <br />Sum Location: L CA r S 7S n Sump Location: <br />Sum Location: - 'J.� Sum Location: <br />Sum Location: Sum Location: <br />7 S ill containment structures are free of water, debris, and hazardous substance. N NA <br />Y <br />Tank 1 — Contents: t XN ✓ Tank 3 — Contents: <br />Tank 2 — Contents: �� ✓ Tank 4 —Contents: <br />8 Under -di user containment areas are free of water, de ris, and hazardous substance. Sensors are located rN erly. <br />NA <br />Y <br />112 Dis enser 9 / 10 <br />314 Dispenser 11 / 12 <br />516 Dis nser 13 / 14 <br />718 Dis enser 15 / 16 <br />PAPERWORK INSPECTION <br />412Tank <br />Monitorin s stem certification has been co t <br />Secon containment tests h--,- <br />on <br />ave been cA let <br />Sill containment ti tress testis was com leted within rec <br />Le ti tness testis was com leted within <br />Other uired testis maintenance was com le <br />Test/Maintenance: <br />Test/Maintenance: <br />d within past 12 months. <br />within the required timeframe. <br />mpleA within the past year. <br />red timeframe. <br />ed timeframe. <br />l within required timeframe. (1 <br />Page 1 of 2 <br />[_N_NA I DATE DONE <br />November 2004 <br />