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t � <br /> Attachment A <br /> Designated Underground Storage Tank(UST)System Operator <br /> Monthly Visual Inspection <br /> Facility Name: Date: _O — O <br /> Facility Address: Tl,'rn <br /> City: o. Zip Code: <br /> Name of Designated UST Operat r Conducting the Inspection: <br /> International Code Council#: Ct Expiration Date: <br /> Signature: Phone: 01�� t r O y 6 <br /> Item Monitoring Panel/Alarm History Y N <br /> 1 Monitoring System is powered on and in proper operating mode. <br /> 2 Monitoring system is not currently showing any alarms or warning. <br /> 3 Alarm history report/log for the previous month is available and has been reviewed by the Designated UST <br /> Operator. (Attach a copy of the alarm history report/logreport/log to this form) <br /> 4 Each alarm for the previous month has been responded to appropriately. <br /> 5 Sensors located in the tank-top containment have not alarmed in the past month. <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. If sump inspection is <br /> required,record results in item 6,below. <br /> UST System Inspection <br /> Note:Visual inspection of sumps is only required in sumps where an alarm has occurred in the past month for which there is no service Y N <br /> record <br /> 6 Tank-top containment sumps are free of water,debris, and hazardous substance. Sensors are properly <br /> located. <br /> Sump Location Sump Location <br /> 7Sill containment structures are free of water, debris, and hazardous substance. <br /> Spill Containment Location Spill Containment Location <br /> 8 Under-dispenser containment areas are free of water, debris, and hazardous substance. Sensors are <br /> properlylocated. <br /> r` Y N NA .-, Y N NA <br /> Dispenser 1/2 Dispenser 9/10 <br /> Dispenser 3/4 Dispenser 11/12 <br /> Dispenser 5/6 Dispenser 13/14 <br /> Dis enser 7/8 Dispenser 15/16 <br /> Paperwork Inspections Y N NA <br /> 9 Monitoring system certification has been completed within the last 12 months. — <br /> 1 <br /> Secondary containment tests have been performed in the last 36 months. — <br /> 1 <br /> Spill containment structure bucket testing was completed in the past 12 months. Z— <br /> 12 Leak detector testing was completed in the past 12 months. <br /> 13 Tank tightness testing was completed within the required time frame. X <br /> 14 Line ti htness testing was com leted within the required time frame. X <br /> Facility Employee Training a Y N <br /> 15 All facility employees have received the required "on-the-job"training within the past year. <br /> 16 All facility employees hires within the past 30 days have received the required"on-the-job"training <br /> CADO_Designated UST 3-23-05.xis3/24/05 Page 1 of <br />