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Nov 19 07 04: 37p Rfforda Test (2091 744-0116 p. e <br /> Monthl In Pection - Page 2 of 2 <br /> PAPERWORK INSPF'CT ION Y N NA Date Done <br /> Moni oring system certification within past 12 months <br /> Spill Bucket testing com lctcd within 12astJ.2 monTlis 0 0 <br /> I0.1� vL <br /> The above erre usually ilorle together an an annual basis for local regulator: <br /> Dine Tightness (uslially a on construction or when no positive shutdown X 10__71, v <br /> -fa nlc Ti fitness (usually offlz after constniction or when using SIR) <br /> S,(wondary containment(SB989) tests have been com feted (usually eye3 -Ifw <br /> Other testis or maintenance comete as required_ List them helow: <br /> Tcst/Waintenance: <br /> Tcstlmaintenancc: <br /> 'lcsVMaintcnancc: <br /> Comments: Alr,,41 l/t 11 —` <br /> - <br /> ,� st <br /> Items Requiring Follow-up Actions: <br /> Monthly inspection must be conducted by an ICC licensed.Designated Operator. <br /> A copy of this checklist must be provided to UST owner or operator, but not to State Watcr Resources. <br /> Designated Operator must alert the UST owner or operator of any condition discovered during the <br /> monthly inspection that may require follow-up action. <br /> UST owner or operator must maintain a copy of this monthly inspection and any attachments for the <br /> previous 12 monllis. Records must be ziaai.ntai.rted on-site or, if approved by the local agency, off.-site , <br /> a readi ly available location. <br />