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Designated Underground Storage Tank. (UST) Operator <br /> Monthly Visual Inspection Checklist <br /> Facili Narne: /"t r o Date: 1�7 "7 <br /> Facili Address: `�d t_ f d<--rc -d, tai <br /> .moo <br /> Cit Zi Code: S-.Z c>Q_ <br /> Desi aced UST Operator the Inspection: .,C/; <br /> International C e ; ci � 1 n#: S . `c3 Lt"1 v" Expiration Date: v /h / � ov(, <br /> Si ature: PA vai4, <br /> V=Yes,N=No,NA=No(Applicable <br /> Item MONITORING PANEL/ALARM HISTORY N NA <br /> Y <br /> 1 Monitoring system is powered on and in pro er operating rnode. <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 /> Desi nated UST Operator. (Attach a=o the alarm history report/logreporillog to thisform if available.) <br /> 4 Each alarm for the previous month has been responded to appropriately. <br /> 5 Sensors located in tank-top containment stumps have not alarmed in the past month. <br /> 5a - List all tank-top sumps where alarms occurred in the past month: <br /> Note:Sumps where an al 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. <br /> 1'sump inspection 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 o sums is only requi ins s where an alarm has occurred in the past month or which there is no service record. <br /> Y N N � <br /> Y <br /> Sump Location: Sump Location: <br /> Sump Location: Sump Location: <br /> Sump Location: Sump Location: <br /> 7 S ill containment structures are free of water,debris,and hazardous substance. <br /> Y N NA I NA <br /> Y <br /> Tank I -Contents: Tank 3-Contents: <br /> [Tank'!-Contents: Tank 4-Contents: <br /> 8 Under-dispenser containment areas are free of water,debris,and hazardous substance. Sensors are located properly. <br /> Y N NA N NA <br /> Y <br /> Dis e?ser 1/2 Dispenser 9110 <br /> _Dispenser 3/4 Dispenser 11/12 <br /> Dis enser S/6 v Dis nser 13/14 <br /> Dis etrser 7/8 Dispenser 15 116 <br /> PAPERWORK INSPECTION N NA DATE DONE <br /> Y <br /> 9 Monitoring system certification has been completed within past 12 months. - "( <br /> 10 Secondary containment tests have been completed within the required timeframe. ✓ %/ 17-U 1 <br /> I 1 Spill containment structure(bucket)testing was completed within the past year. - v <br /> 12 Tank figh[Hess 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 fest/maintenance items below. <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> Page 1 of 2 November 2004 <br />