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09/29/05 09:37 FAX 925 422 2748 EPD / WGMG IM 002 <br /> Designated Underground Storage Tank(UST) System Operator <br /> Monthly Visual Inspection Checklist <br /> Facili!y Name: /-IRK 5 91 1 Date: 2 <br /> Facility Address: e • okd <br /> City: I r­ar_ Zi Code; cjYJZ4 <br /> Designated UST Operatoi Conducting the Inspection: r-O c, <br /> ICC Cert.#: z,/S7/8-t!/ .Da7k:0 lel <br /> Signature: Phone: <br /> U % Y=YSN=Nu, A-No(A Ucable <br /> Item N MONITORING PANEL ALARM FIT.IFTOORRY Y N NA <br /> ....... ....... <br /> 12�1 _SL4011-11 Z..'rgp gg <br /> vp gg <br /> r Z..& <br /> I Monitoring system is powered on and in proper operating mode. <br /> 2 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 or"I.-alarm histo re ort/to to this i <br /> o n fo rm,) <br /> 4 Each alarm for the pr4;vii s month has been to <br /> 5 Sensors located in tank-top containment sumps have not alarmed in the pastonth. <br /> 5a List all tank-top sumps where alarms occurred in the past month: -1 <br /> Note:Sumps where an alarm has occurred in thepast month must be inspected unless a qualified service technician responded to,and <br /> properly <br /> addressed the cause of the alarm.Documentation verjoing appropriate service should be attached to this report• <br /> lfwmp i1is u4e <br /> !A-95PMA�.01 gA results should be recorded in Item 6.below, <br /> UST SYSTEM INSPECTION <br /> 6 Tank-top containment sumps are free of water,debris,and hazardous substance. <br /> Note:Visual ins ection ofsumps is onl re uired in sumps where an alarm has occurred in the j2ast month or which there is no servicer record <br /> Y N Y N <br /> Sump Location: Sum Location: <br /> SUMD Location: '7.lmp Location: <br /> 7 Spill containment structures are free of water,debris,and hazardous substance. <br /> Y N NA Y N NA <br /> Tank I-Contents: Tank 3-Contents: <br /> Tank 2-Contents: Tank 4-Contents: <br /> 8 Under-dispenser containment areas are free of water,debris,and hazardous substance. <br /> Y I N I NA Y N NA <br /> Dispenser 1 2 Dispenser 7/8 <br /> Dispenser 3 4 Dispenser 9/10 <br /> Dispenser 5 6 biS_penser 11/12 <br /> 9 Leak detection is properly located within under-dispense.-contairunent. <br /> Y N NA Y N INA <br /> Dispenser I/2 Dispenser 7/8 <br /> DiTenser 3/4 Dispenser 9/10 <br /> Dispenser 5/6 Dis enser 11/12 <br /> PAPERWORK INSPECTION Y N NA DATED NE <br /> 10 Monitoring system certification has been completed within past 12 months. 26 <br /> 11 Secondary containment tests have been c�m leted within theguired timeframe.=e. -4 y <br /> P <br /> 12 Spill containment structure bucket testin was completed within the past 12 months. X <br /> 13 Tank tightness testing was completed within required timeframe. <br /> �0 <br /> 14 Line tightness testing was completed within required timeframe. <br /> 15 Other repired testing/maintenance was completed within required timeframe. (List test/maintenance items below.) <br /> TestlMaintenance: <br /> TestlMaintenance: <br /> TestlMaintenance: <br /> FACILITY EMPLOYEE TRAINING N NA <br /> 16 All facili!X eT21oyees have received the required on-the-job training within the past year. <br /> 17 All facili!j eMEloyees hired within the past 30 das have received the ouired on-the job train.... <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 />