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Designated Underground Storage Tank(UST)System Operator <br /> Monthly Visual Inspection Checklist <br /> Facility Name: C 04, Date: y <br /> Facili Address: A37S- Ill. <br /> Ci 'rZip XAla <br /> Code: <br /> Designated UST Operator S_nducfing the ction: <br /> ICC Cert.#: Exp.Date: I / <br /> Si • ture: Phone: <br /> Y s Y N=No NA s Nat Anplicabie <br /> Item# MONITORING PANEL/ALARM HISTORY Y N NA <br /> 1 Monitorin system is powered on and itt o er era ' mode. <br /> 2 Monitorin s stem is not cu rentl showin an leak.aiarms. <br /> 3 Alarm history report/log for-the previous month is available,and has been reviewed by the <br /> Desi ted UST 2perat6r. Attach a cojV o the alarm histo r rt/lo to this ins cellon orm <br /> 4 Each alarm for the previous month has been responded to appropriately. <br /> 5 Sensors located in tank-top containment s2Ms 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 monsh must be inspected unless a qualified service technician responded to,and <br /> properly addrwsrA the cause of the alarm.Documentation verifying appropriate service should be attached to this report. <br /> / sum i tion is uir ed.results should be recorded in item 6,below. <br /> UST SYSTEM INSPECTION <br /> [ff6 Tank-top containment sumps are free of water,debris,and hazardous substance. <br /> Note:Visual Lkspection?L__mps is on uired is sumps where an alarm has occurred in the past month r which there is no service record <br /> Y N Y N <br /> Sum Location: Sum Location: 1 <br /> Sum Location: Sum Location: <br /> 7 Spill containment structures are free of water,debris,and hazardous substance. <br /> Y N NA I YJ N I NA <br /> Tank 1-Contents: Tank 3-Contents: 17 <br /> - Tank2=Contents: _ ._ .__ -1'�" '­ .,•_ ..Tank 4-Contents: -__ ..0�' ._ _ A 1, <br /> 8- Under-dispenser containment areas are free of water,debris and hazardous substance. <br /> Y N INA Y N INA <br /> Dispenser 1/2 Dispenser 7/8 <br /> Dispenser 3/4 Dispenser 9110 <br /> Dispenser 5/6 Dispenser 11/12 <br /> 9 Leak detection is properly located within uider-dis 3enser containment. <br /> Y N NA Y -N I NA <br /> Dispenser 1/2 Dia eraser 7/8 <br /> Dispenser 3/4 Dia enser 9110 <br /> Dispenser S/6 Dis enser 11/12 <br /> PAPERWORK INSPECTION Y. Y N I NA I DATE DONE <br /> 10 Monitoring system certification has been co` feted within past 12 months. <br /> 11 Secondary containment tests have been completed within the required timeframe. <br /> 12 Spill containment structure(bucket)testing was completed within the past 12 months. <br /> 13 Tank ti fitness testing was com pleted within ed timeframe. <br /> 14 Line tightress testing was completed within required timeframe. <br /> 15 Other required testis maintenance was completed within required timeframe. List test/maintenance iterns below. <br /> TestlMaintenance: <br /> TestlMaintenance: <br /> TestlMaintenance: <br /> ;.- .. <br /> FACILITY EMPLOYEE TRAINING Y I N I NA <br /> =17AII <br /> li to ees have received the re uired on-the-ob trainin within the ast ar. <br /> li a to ees hired within the ast 30 da have received the re uired on-the-'ob training. 44— <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 />