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Designated Underground Storage Tank(UST) Operator <br /> Monthly Visual Inspection Checklist <br /> Facility Name: Z7 76-clvrDate: /d" <br /> Facility Address: 0,1- <br /> Ci : 16-;%o I Zip Code: <br /> Designated UST Operator Conducting the Inspection: Jerry Zimowske <br /> International Code CotpvdMertificatioa4k 5249080-U Expiration Date: 12 / 1 /2006 <br /> Si nature: Phone: 510 364-4452 <br /> Y=Yes,N=No,NA—Not Applicable <br /> Item MONrrORING PANEL/ALARM HISTORY Y N NA <br /> 1 Monitoring system is powered on and in proper operating mode. v <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/l4 to this orm i available. <br /> 4 Each alarm for the previous month has been responded to appropriately. <br /> v <br /> 5 Sensors located in tank-top containment sumps 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 alarm has occurred in thepast 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 /> ! <br /> sump 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 onl&y required in sum s where an alarm has occurred in thepast month or which there is no service record. <br /> Y N <br /> Sump Location: ump 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 INAI Y I N I NA <br /> Tank 1-Contents: r/ Tank 3-Contents: *44?_ <br /> Tank 2-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 Y N I NA <br /> Dispenser 1/2 t/' Dispenser 9/10 ti <br /> Dispenser 3/4 Dispenser 11/12 <br /> Dispenser 5/6 Dispenser 13 114 <br /> Dispenser 7/8 Dis enser 15/16 v <br /> PAPERWORK INSPECTION Y N NA DATE DONE <br /> 9 Monitoring system certification has been completed within past 12 months. 91 <br /> 10 Secondary containment tests have been completed within the required timeframe. .►a <br /> 11 Spill containment structure bucket testing was completed within the past year. P, -+C <br /> 12 Tank tightness 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 /> Test/Maintenance: <br /> FACILITY EMPLOYEE TRAINING Y I N I NA <br /> 15 All Facili employees have received the required on-the-job trainin within the past year. <br /> 16 1,All facili employees hired within the past 30 days have received the Muired on-the-job training. <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 />