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;a. <br />Ole <br />Vv ssX�. ® V _- <br />Designated Underground Storage Tank (UST) System Operator <br />Monthly Visual Inspection Checklilit <br />Facility Name: ✓, Date: / <br />FacilityAddress: <br />' Code: <br />Desi nated U rator Conductingthe Inspection: <br />ICC <br />. Date: <br />Si nature: / <br />Phone: <br />Y -Y N -N NA-N.t ApplicaWe <br />Item # MONITORING PANEL / ALARM $ISTORY I Y I N I NA <br />1 I Monitoring system is powered on and is propera mode. <br />2 1 Monitoring system is not currently showing any leak.alarms. <br />3 Alarm history report / log for the previous month is available, and has been reviewed by the <br />Designated UST Operator. Attach a co& o the alarm history report /!M to this ills norm <br />4 1 Each alarm for the previous month has been responded to appropriately . <br />5 Sensors located intankmtop containment sumps have not alarmed in the past month <br />53 List all tank -top sumps where alarms occurred in the past month: <br />Note: Sumps where an alarm has occurred in dupwi month must be inspected unless a gadied _Wce technician responded% and <br />properly addressed the muse ofthe alarm. Documentation verifying appropriate service should be atindtad to this report. <br />If.... I ulna is a%rad, results Jhould be seri nand in Pon a, below. <br />UST SYSTEM IPISPECTION <br />6Tank-top <br />containment sumps are free of water debris, and hazardous substance. <br />Note: Vimol inoisettionofukm is —?Z in where an alarm has accused in the past month k, which there is as service ruwd <br />Y N Y N <br />Sump Location: Location: <br />Sump Location: Sump Location: <br />7 <br />Spill containment structures are free of water debris and hazardous substance.Y <br />N NA Y N NA <br />Tank 1 - Contents: Tank 3 - Contents: <br />Tank 2 - Contents: Tank 4 -Contents: <br />8 <br />Under -dispenser containmentareas are free of water, debris and hazardous substance. <br />Y N NA Y N NA <br />Dispenser 112 Des nser7/8 <br />Dis enser3/4 V4 I I Dispenser 9/10 <br />Dispenser S / 6 Dispenser 11 / 11 <br />9 <br />Leak detection isro I located within undo- ' r containment. <br />Y N NA Y I N I NA <br />Dispenser 1/ 2 Dispenser 7 / 8 <br />Dispenser 3 14 Dispenser 9/10 <br />Dupenser,516 Des enser11/11 <br />PAPERWORK INSPECTION IYJ N I NA I DATE DONE <br />10 1 Monitoring system certification has been corryleted within past 12 months. <br />11 Seco containment tests have been completed within the re ' ed timeframe. <br />12 Spill containment structure(bucket) testing was completed within the past 12 months. <br />13 Tank tightness testis was completed within required tittxframe. <br />14 Line tightness testing was completed within required timeframe. <br />15 Other required tesfin maintenance was completed within required ornefrarre. List test/maintenance items below. <br />Test/Maintenance: <br />TesdMamlenance: <br />Test/Maintenance: <br />FACILITY EMPLOYEE TRAINING Yu Nl NA <br />16 All facile to ea have received the required on-the-'obc""m within the ast ear. <br />17 1 All facile em to es hired within the st 30 de have received the re uired on-the-job training. <br />note: Any answer of nN- snomo re expiamea in the comment section on tae tonowing page, and will require <br />follow-up action from the UST owner/operator. <br />Page 1 of 2 <br />