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Designated Underground Storage Tank(UST)System Operator <br /> Monthly Visual Inspection Checklist <br /> Facility Name: j Date: .21 / <br /> Facility Address: e. / <br /> city..7XAS e I Zip Code: <br /> Desi ted 118T Operator Conducting the tion: <br /> ICC Cert.#: ft.Date: / I <br /> Signature: Phone: <br /> Y s Y N=N NA t o Iicable <br /> Item# MONITORING PANEL/ALARM HISTORY Y N NA <br /> 1 Monito ' j s stem is powered on and in prow operating mode. K <br /> 2 Monitoring system is not cuaen l sho any leak•alarms. <br /> 3 Alarm history report/log forthe previous month is available,and has been reviewed by the <br /> Designated UST Operator. Attach-a copy 9f the alarm history report/lM to this " ectionorm. <br /> 4 Each alarm for the revious month has been onded to ria <br /> r tel . ' <br /> 5 Sensors located in tank-Log containment s have not alamied 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 gualilled service technician responded to.and <br /> properly addressed;the cause of the alarm.Documentation werih4ng appropriate service should be attached to this report. <br /> /sum ins action is muirart results should be recorded in item t3 below. <br /> > 4' .. .. <br /> AA <br /> UST SYSTEM INSPECTION ' <br /> VS ., <br /> containment sumps are free of water,debris,and hazardous substance. <br /> ual Impaction is on u' in sumps where an alarm has occurred'in the ost monthAr which there is no service record <br /> Y N Y N <br /> ation. 7 Su Locatication: $'q Sum Location: <br /> 7 1 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: 91 <br /> Tank 2--Contents: ¢g Tank 4—Contents: 9#1 <br /> 8- Under-dispenser containment•areas are free of water,debris,and hazardous substance. <br /> Y N NA Y_ I N I NA <br /> D' eraser 1/2 Dis eraser 7/8 <br /> D" enser 3/4 Dis eraser 9110 <br /> Dispenser S/6 Dispenser 11/12 <br /> 9 1 Leak detection is r located within under eraser containment <br /> Y N I NA Y N NA <br /> D' ienser 1/2 Dispenser 7/8 <br /> D' nser3/4D' eraser 9/10 <br /> D nser�S/6 Dis eraser 11/12 <br /> PAPERWORK INSPECTION Y N NA DATE DONE <br /> 10 . Monitorin s stem certification has been completed within ast 12 months. <br /> 11 Sec2aln containment tests have been completed within the r uired timeframe. <br /> 12 Spill containment structureucket trsgqg was co feted within the East 12 months. <br /> 13 Tank tightness testin was pmpleted,within r aired timeframe. <br /> 14 Line tightness tesgpj was co leted within Leguired timeframe. <br /> 15 Other required testin0maintenance was co leted 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 /> 16 All fa " employees have received the r fired on-the-job training within the 2ast year. <br /> 17 All facilia to ees hired within the East 30 da have received the re uired 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 />