Laserfiche WebLink
i <br /> Designated Underground Storage Tank(UST)-System Operator <br /> Monthly Visual Inspection Checklist <br /> Facility N I Date: </ .1/ . r / <br /> FaciliAddress: Mitch <br /> Ci Code: <br /> Designated 118T OperatoTConducting the ction: <br /> ICC Cert.#: EV.Date: <br /> Si tore: Phone: <br /> YYes,N-Na.NA s Not Applicable <br /> ra - <br /> MONITORING PANEL/ALARM HISTORY Y N NA <br /> OWN <br /> rin system is owered on and in ra o tia made. K <br /> nin s stem is not currently showingan leak alarms. <br /> history report/log for the previous month is available,and has been reviewed by the <br /> ted UST tor. Attach a co o the alarm histo report/lo to this ' ection orm <br /> arm for the revious month has been onded to appropriately. <br /> s located in tank-t containments s have not alarmed in the past month <br /> t all tank-top sumps where alarms occurred in the pastmonth: <br /> Note:Sumps where an alarm has occurred in the past mattth must beinspected unless a qualified service technician responded to,and <br /> properly address&$the cause of the alarm.Documentation wer fying appropriate service should be attached to this report. <br /> /sum ens tion is uiretl,twulu should be recorded in item 6,below. <br /> -9 Zeti _ <br /> UST SYSTEM INSPECTION <br /> 6 Tank-top containment sumps are free of water,debris,and hazardous substance. <br /> Note:Visual inspection o su s is only 22u. in sumps where an alarm has occurred in the past month.&r which there is no ser4ce record <br /> Y N SM Y N <br /> Sum Location '' Sump Location: 41 <br /> 'Sump Location: T q Pe JWLum Location: <br /> 7 Spill containment structures are free of water,debris,and hazardous substance_ <br /> Y • N NA Y N NA <br /> Tank 1 —Contents: Tank 3—Contents: 1 <br /> Tank2--Contents: t4 Tank 4—`Contents: <br /> 8- Under-dis eraser containment areas are free of water,debris,and hazardous substance. <br /> Y N NA Y N NA <br /> Dis eraser <br /> 112 ##DJspEenserJ1112 <br /> ' er 718 <br /> Dis eraser <br /> 314 Dispenser er 9/10 <br /> Dispenser S/6 <br /> 9 Leak detection is ro 1 located within under-dispenser containment. <br /> Y N INA I Y I N I NA <br /> Dispenser 112 Dis eraser 7/8 <br /> Dispenser 3/4 Dis ewer 9110 <br /> Dispenser S/6 Disp <br /> zenser 11/12 <br /> PAPERWORK INSPECTION Y N NA I DATE DONE <br /> 10 Monitoring system certification has been completed within past 12 months. <br /> 11 Secondary containment tests have been co leted within the required firneirame. <br /> 12 Spill containment structure ucket tes!!R&was completed within the past 12 months. <br /> 13 Tank tightness testing was co leted within required timeframe. <br /> 14 Line tightness testing was co221eted within required timeframe. <br /> 15 Other required testis maintenance was completed within required timeframe. List test/maintenance items below. <br /> TestlMaintenance: <br /> Tes Waintenance: <br /> Test/Maintenance: <br /> FACILITY EMPLOYEE TRAINING Y� N NA <br /> 16 All facility employees have received the required on-the-'ob training within the past year. <br /> 17 Ail facili a to es hired within the,past 30 da s have received the re ed on-the-'ob 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 from the UST owner/operator. <br /> Page 1 of 2 <br />