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i <br />6 <br />�IAWVIN MiNzq 1=1 1111;MM <br />Facility Name: ✓P P Date: / / S/,G� o /_ D <br />Facility Address:Z 7 S�/i/ .TXiaB /3 ✓ <br />Ci d Zi Code• <br />Desi Hated ST 2perator Conducting the ection: <br />ICC Cert. #: U i. Exp. Date: / / ja/ <br />Si nature: , • Phone: l- S• <br />YYS N=N NA - Not A <br />Item # MONITORING PANEL / ALARM HISTORY Y N <br />1 Monitoring system is powered on and in ro ero eratin mode. <br />2 Monitoring system is not current!y showing any leak alarms. y® <br />3 Alarm history report / log for the previous month is available, and has been reviewed by the <br />Desi ated UST Operator. Attach a copy.of the alarm history re ort / log to this ins ection arm. <br />4 Each alarm for the previous month has been LeRonded to appro2riatel . <br />5 Sensors located in tank -top containment sumps have not alarmed in the past month t/ <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 be inspected unless a qualified service technician responded to. and <br />properly addressed, the cause of the alarm. Documentation verifying appropriate service should be attached to this report. <br />1 sum ins ecdon is required, results should be recorded in item 6. below. <br />UST SYSTEM INSPECTION <br />rrsa�r <br />M <br />6 <br />Tank -top containment sumps are free of water, debris, and hazardous substance. <br />Note: Visual ins action o sum s is only uired in sumps where an alarm has occurred in thepast month or which there is no service record <br />Y <br />I N UM <br />Sum Location: <br />YJ <br />N OW <br />Sump Location: P 7 <br />Sum Location: <br />Sum Location: <br />7 <br />Spill containment structures are free of water, debris, and hazardous substance. <br />Y I. N NA <br />Y <br />N NA <br />Tank 1 -Contents: Tank 3 - Contents: <br />Tank 2.—Contents: _ Tank 4 - Contents: <br />8 <br />Under-dis enser containment areas are free of water, debris, and hazardous substance. <br />Y I N I NA I <br />Y <br />N INA <br />Dls eraser 1 / 2® Dis enser 7 / 8 <br />Dispenser 3 / 4 ✓ Dispenser 9110 <br />Dispenser S / 6 Dispenser 11 / 12 <br />9 <br />Leak detection is propeft located within under -dispenser containment. <br />Y N I NA <br />Y <br />N NA <br />Das enser 1 / 2 Dispenser 7 / 8 <br />Dispenser 3 14 Dispenser 9110 <br />Dispenser, S / 6 Das enser 11 / 12 <br />PAPERWORK INSPECTION Y N I NA DATE DONE <br />Monitoring system certification has been completed within 2ast 12 months. <br />1 I Seconda contatntn have been ompleted within the required timeframe. <br />12 Spill containment structure uc was completed within the past 12 months. <br />13 Tank tightness testing was completed within timeframe. <br />14 Line tightness testig& was completed within required time <br />15 Other required testis maintenance was completed within required t' e. t/maintenance items below.) <br />TestlMaintenance: <br />FACILITY EMPLOYEE TRAINING Y <br />16 All facili a Io ees have received the re u -I <br />oes ' ed within the past 30 da shave received the required 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 />Pagel of 2 <br />