Laserfiche WebLink
Afforda-1eU <br />800 524-9087 FAX 209 794-0112 <br />Designated Operator <br />Monthly Inspection Checklist <br />Facility Name: <br />— <br />Facility Address: (;;c)U <br />1,401A <br />N <br />Chy: -, <br />Zi <br />Designated UST Operator Conducting the Inspection:- <br />� r <br />Internationa o e Cou it Certification #: 5 ZLv <br />-Signature: <br />- U <br />Expiration Date: <br />I Phone: (z0 <br />m <br />r <br />1vA <br />MONITORING PANEL / ALARM HISTORY <br />= <br />Y <br />1,401A <br />N <br />Ilc9ble <br />NA <br />1 <br />Monitoring system is powered on and in proper operating mode. <br />2 <br />Monitoring stem is not currently showing any alarms or warnings. <br />3 <br />Alarm history report/log for the previous month is available, and has been reviewed=the <br />Designated UST Operator. (Attach a co o the alarm histo re ort/lo to thisform <br />4 <br />Each alarm for the previous month has been responded to appropriately. <br />5 <br />Sa <br />Sensors located in tank -top containment sumps have not alarmed in the past month. <br />_ List all tank -top sumps inhere alarms occurred in the past month: /l i_!A) A? <br />Note: Sumps where an alarm has occurred in the past month mast 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, uired, 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 sum s is only re uired in sour siphere an alarm has occurred in the post month or which there is no service record. <br />Y <br />N <br />ri <br />Y <br />Sump Location: <br />Sump Location: <br />Sump Location:Sump <br />Location: <br />Sump Location: I <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: <br />Tank 3 - Contents: <br />Tank 2 - Contents: <br />Tank 4 - Contents: <br />ment areas are <br />Under -dispenser containfree of water, debris, <br />-free <br />and hazardous substance. Sensors are located properly. <br />Y N INA <br />N NA <br />Y <br />Dispenser 1/ 2 <br />Dispenser 3 / 4 <br />Dispenser 5 / 6 <br />Dispenser 9 / 10 <br />Dispenser 11 / 12 x' <br />Dispenser 13 / 14 <br />Dispenser 718 <br />Dis enser 15 / 16 <br />PAPERWORK INSPECTION <br />Y <br />N NA DATE DONE <br />9 Monitoring system certification has been completed within past 12 months. <br />10 Secon—dary containment tests have been completed within the required timeframe. X <br />11 Spill containment structure (bucket) testing was completed within the past year. <br />12 Tank ti htness testing was completed within required timeframe. <br />13 Line tightness testing was completed within required timeframe. <br />14 Other required testing/maintenance was completed within required timeframe. (List test/maintenance items below.) <br />Test/Maintenance: <br />Test/Maintenance: <br />