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6 <br /> Designated Underground Storage Tank(UST)-System Operator <br /> Monthly Visual Inspection Checklist <br /> Facility Name: Date: .S' // <br /> Facility Address: 7 4j , 09Sr <br /> Ci _Code: <br /> Desi&2ated UST Operator Conducting the 'on: <br /> ICC Cert.#: Exp.Date: <br /> Signature: Phone: <br /> Y—Y N-N NA-Not Applicable <br /> Item# MONITORING PANEL/ALARM HISTORY Y N NA <br /> 1 Monito ' tem is Eowered on and in pLqer. mode. <br /> 2 Monitoring s stem is not cwmtly showing leak.alarms. <br /> 3 Alarm history report/log for the previous month is available,and has been reviewed by the <br /> Desi ted UST tor. Attach a co othe alarm histo report/to to this i ectaon o/mt. <br /> 4 Each alarm for the pLmjous month has been re n led to NTLoLnately. <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 the past month must beinspected unless a qualified service technician responded to,and <br /> property addressed,the rouse of the alarm.Documentation verifying appropriate service should be attached to this report. <br /> /sum ins tion is uired,results should be recorded in item 6,below. <br /> x°S�.i` p4Uhelv:p-t....I }Y.. '.1"•'- `.).ice `;{ G>!'. 5M <br /> UST SYSTEM INSPECTION <br /> 6 Tank-top containment sumps are free of water,debris,and hazardous substance. <br /> Note:risual' ection o s is on aired in su where an alarm has occurrer!in the past month r which there is no service record <br /> Y' N Y N <br /> Su Location Sum Location: t fi= <br /> S Location: Sum Location. <br /> M__ <br /> 7 S ill containment structures are free of water,debris,and hazardous substance. <br /> Y I. N I NA I Y I N INA <br /> Tank 1—Contents: 97 2f I I I Tank 3—Contents: 1 <br /> Tank 2—Contents: kEEjTank 4—Contents: p; <br /> 8' <br /> Under-dispenser containment areas are free of water,debris,and hazardous substance. <br /> Y N NA I Y N NA <br /> Dis enser 112 X Dispenser 7/$ <br /> Dispenser 3/4 Dispenser 9110 <br /> Dispenser 5/6 Y Dispenser 11/12 <br /> 9 Leak detection is properly located within under-dispenser containment. <br /> Y N I NA Y N NA <br /> D' enser 112 Dis enser 7/8 <br /> Dieraser 3/4 Dispenser 9110 <br /> Dir enser 5/6 Dis eraser!/112 <br /> .ax -:dc a ;fa -- .}:.;-. :•,.._::-r_'�:L .u:t� .. <br /> PAPERWORK INSPECTION_ Y N I NA DATE DONE <br /> 10 Monito * system certification has been co leted within past 12 months. <br /> I 1 Secondary containment tests have been completed within the r aired timeframe. <br /> 12 Spin containment structure(bucket)tes!jR&was co leted within the East 12 months. <br /> 13 Tank 'Shtness testing was co ]eted within required timeframe. <br /> 14 Line ti tress testing was completed within required timeframe. <br /> 15 Other required testis maintenance was completed within required timeframe. List test/maintenance items below. <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> .,:.:• I - <br /> x <br /> FACILITY EMPLOYEE TRAINING YT I N I NA <br /> 16 All facilityemployees have received the required on-the-•ob trainin within the past year. <br /> 17 All facili a to es hired within the past 30 dM have received the re ed on-the-'ob tr ' <br /> Note: Any answer of"N"should be explained in the comment section on the following page,and will require <br /> follow-up action from the UST owner/operator. <br /> Page 1 of 2 <br />