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Designated Underground Storage Tank(UST)System Operator <br /> Monthly Visual Inspection Checklist <br /> Facility Name: GCo S I/ 1C e. Date: <br /> Facili Address: .13 S' Tc s'r-, <br /> Ci Z' Code: <br /> Designated UST rator onductin the action: <br /> ICC Cert.4 E Date: <br /> Signature: Phone: <br /> Y-Yes,N—No.NA=NotApplicable <br /> Item# MONITORING PANEL/ALARM HISTORY I Y I N INA <br /> 1 Monitoring system is powered on and in proper o eratin mode. <br /> 2 Monitoring system is not currently showing 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 co o the alarm histo r ort/lo to this ins action arm. <br /> 4 Each alarm for the previous month has been responded to appropriately. <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 thepast month must beinspected unless a qualif►ed service technician responded to,and <br /> properly addressed,the cause of the alarm.Documentation verifying appropriate service should be attached to this report. <br /> ins action is re wired,results should be recorded in item 6,below. <br /> IFElion' <br /> rs3.� :T?�T?,..�- a Y.i �� .�. :i%vJ.R.7 - c_:nz..i. .:e:'.�m: `F. - •� '1.rUST SYSTEM INSPECTION <br /> ontainment sumps are free of water,debris,and hazardous substance. <br /> al ins ection o'sum s is onl u' in su s where an alarm has occurredin the ast month or which there is no service record <br /> Y N Y N EMtionSum Location: Ct: __M Sum Location: <br /> 7 Spill containment structures are free of water,debris,and hazardous substance. <br /> Y N NA I Y N NA <br /> Tank i-Contents: 82 y I Tank 3—Contents: 9 <br /> Tank 2-Contents: kl 70 Tank 4-Contents: Qi/ <br /> 8 Under-dis enser containment areas are fide of water,debris,and hazardous substance. <br /> Y N NA Y N NA <br /> Dispenser 1/2 Dir enser 7/8 <br /> Dispenser 3/4 Dispenser 9110 <br /> Dispenser S/6 Dispenser 11/12 <br /> 9 Leak detection is properly located within under-dis eraser containment. <br /> Y N NA Y I N I NA <br /> Dispenser 1/2 Dispenser 718 <br /> Dispenser 3/4 "It Dispenser 9110 <br /> Dispenser 5/6 Dispenser 11/12 <br /> PAPERWORK INSPECTION JYJ N NA- DATE DONE <br /> 10 Monitoring system certification has been completed 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 tightness testing was completed 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 /> TestlMaintenance: <br /> TestlMaintenance: <br /> Test/Maintenance: <br /> MEN <br /> FACILITY EMPLOYEE TRAINING Y I NINA <br /> 16 All facility employees have received the required on-the-'ob training within the past year. <br /> 17 AlI facili a to ees hired within the 2ast 30 da have received the required 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 /> Pagel of 2 <br />