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Designated Underground Storage Tank (UST) Operator <br /> Monthly Visual Inspection Checklist <br /> Facility Name: JL-6-C19 Date: —70- <br /> Facilit Address: 0't- ry <br /> City: c'5T I Zip Code- <br /> Designated UST Operator Conducting the Inspection: Jerry Zimowske <br /> International Code Co ertificati • 52490WU97 Expiration Date: 12 / 1 /2006 <br /> Signature: Phone: 510 364-4452 <br /> Y=Yes,N=No,NA=Not Applicable <br /> Item 1Nf0NlTnjzTNG PANEL/ALARM HISTORY Y N NA <br /> 1 Monitoring system is powered on and in Eoier operating mode. <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 /> Designated UST Operator. Attach a copy of the alarm history report/loreporft to thisform i available. <br /> 4 Each alarm for the previous month has been responded to appropriately. <br /> v <br /> ----- -- -5- Sensors located in tank-to -contammentsum s have not-alazmed-irrthe ast-montlr.-- <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 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 /> Ysump inspection is re aired,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 re uired in sums where an alarm has occurred in thepast month or which there is no service record. <br /> Y N ;...: Y N <br /> Sump Location: SUT2 Location: <br /> Sump Location: ump Location: <br /> Sump Location: Sump Location: . <br /> 7 Spill containment structures are free of water,debris,and hazardous substance. <br /> Y I N INA Y N NA <br /> Tank i -Contents: ✓ Tank 3-Contents: 7"ew- t/ <br /> Tank 2-Contents: Tank 4-Contents: <br /> 8 Under-dispenser containment areas are free of water,debris,and hazardous substance. Sensors are located ro erl . <br /> Y N NA Y N INA <br /> Dispenser I/2 t/" Dispenser 9/10 v <br /> Dispenser 3/4 Dispenser 11/12 <br /> Dispenser 5/6 v Dis enser 13/14 <br /> Dispenser 7/8 Dispenser 15/16 v <br /> PAPERWORK INSPECTION Y N NA DATE DONE <br /> 9 Monitoring system certification has been completed within past 12 months. ---o <br /> 10 Secondary containment tests have been completed within therequired timeframe. -4 <br /> 1 I Spill containment structure bucket testing was completed within the past year. -+D <br /> 12 Tank tightness testing was completed within required timeframe. -W--0 <br /> 13 Line tightness testing was completed within required timeframe. *1--,1-03 <br /> 14 Other required testin maintenance was completed within required timeframe'. List test/maintenance items below. <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> FACILITY EMPLOYEE TRAINING Y N NA <br /> 15 All facility employees have received the required on-the job training within the past year. <br /> 16 All facili em to ees hired within the East 30 da s have received the required on-the-ob trainin . <br /> Note: Any answer of"N"should be explained in the comment section on the following page,and will require <br /> follow-up action. <br /> Page 1 of 2 September 2004 <br />