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Designated Underground Storage Tank(UST)-System Operator <br /> Monthly Visual Ins ectiou Checklist <br /> Facility Name: Date: <br /> FacilityAddress: I. <br /> Ci Code: <br /> Designated M 2perator Conducting the 'on: <br /> ICC Cert.#: Date: <br /> Signature: Phone: <br /> Y-Y N—N N OtApplicobie <br /> Item# MONITORING PANEL/ALARM HISTORY Y N NA <br /> 1 Monitoring system is powered on and in proper operatTgmode. <br /> 2 Monitoring system is not current!y showin ny leak•alarms. <br /> 3 Alarm history report/log for-the previous month is available,and has been reviewed by the <br /> Desi d UST Operator. Attach a co_vy of the alarm histo reportl log to this in4wWonjorm. <br /> 4 Each alarm for thevious month has been Egonded to appropriately. <br /> 5 Sensors bated in tank- containment sumpshave not alarmed in the past month. <br /> 5 _ List all tank-top sumps where alarms occurred in the past month: <br /> Raw Sumps whine an alarm has occurred in the past month must beinspected unless a qualtried semce technician responded to.and <br /> properly addressed the cause of the alarm.Documentation verlfping appropriate service should be attached to this report <br /> /sum ins tion is uitv4 results should be recorded in item 8,below. <br /> x. , r - <br /> UST SYSTEM INSPECTION <br /> 6 Tank-top containment sumps are free of water,debris,and hazardous substance. <br /> Note:ruual ins -ono sumps is on1byr in sumps where an alarm has occurred in the month for which there is no service mord <br /> Y Y N <br /> Su Location: Sum Dation: <br /> Sum tion: Sump Location: <br /> 7 Spill containment structures are free of water,debris us substance. <br /> Y I N I NA I Y N NA <br /> Tank I—Contents: Tank 3—Contents: l t► <br /> Tank 2—Contents: IM I I Tank 4—Contents: 0.1 X <br /> 8 Under-dispenser containment areas are free of water debris and hazardous substance. <br /> Y I N NA I Y N NA <br /> Dispenser 112 Die eraser 718 <br /> Dispenser 3/4 Dispenser 9/10 <br /> Dispenser S/6 Dispenser 11/12 <br /> 9 Leak detection is pj2ESrIZ located within under er containment. <br /> Y N NA Y N NA <br /> Dispenser 1/2 s"' Dispenser 718 <br /> Dispenser 3/4 Die eraser 9/10 <br /> Dispenser S/6 Die user///12 <br /> PAPERWORK INSPECTION Y N_ NA- DATE DONE <br /> 10 Monitoring s tem certification has been completed within past 12 months. <br /> I 1 Secondary containment tests have been completed within the required timefiame. <br /> 12 Spill containment structure(bucket)to ' was completed within the past 12 months. <br /> 13 Tank tightness testing was completed within required timeframe. <br /> 14 Line ti tness testis was co leted within re aired timell n e. <br /> 15 Other reHired testis maintenance was completed within required timeframe. List test/maintenance items below. <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> TestlMaintenance: <br /> FACILITY EMPLOYEE TRAEqNG Y N NA <br /> 16 All facili a to ees have received the re aired on-the-'ob trainin within the est ear. <br /> 17 All faci!U a 10 ees hired within the st 30 d=have received the reejcd on-the-'ob trainin . <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 />