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09/29/05 09:40 FAX 925 422 2748 EPD / WGMG R1008 <br /> Designated Underground Storage Tank(UST) System Operator <br /> Monthly Visual Inspection Checklist <br /> Facik Name: S,' J o 0 88.2 Date: / oS <br /> Facility Address: r /oma <br /> Ci : `� Zi Code: L7 3 7 <br /> Designated UST® erato Conducting the Inspection: GVE4 1..3. ° 4,t` <br /> ICC Cert.#: S P/? —ti ' E ate: 1 I /17 /c)a'" <br /> Si tore: L Phone: la-o 16 4 <br /> Y-Y N—No NA=Not A lleable <br /> Item# MONITORING PANEL/ALARM HISTORY Y I N NA <br /> 1 Monitorin system is powered on and in pLoTer opera <br /> * mode. <br /> 2 Monitoring system is not currently showin any leak alarms. X L-- <br /> 3 Alarm history report/log for the previous month is available,and has been reviewed by the <br /> Designated UST Operator. attach a copy o Phe alarm history report/to to this inspection orm. _ <br /> 4 Each alarm for the previous month has been responded to a ro riatel . X <br /> 5 Sensors located in tank-top containment sums have not alarmed in the past month. <br /> 5a _ List all tank-top sumps where alarms occurred in the past month: V <br /> Note:Sumps where an alarm has occurred in the past month must be inspected unless a quaked service technician responded to,and <br /> property addressed,the cause of the alarm.Documentation verifying appropriate service should be attached to this report. <br /> I su ins cdon is re wired,results should be recorded in item46, 17g. <br /> n. : .. <br /> UST SYSTEM INSPECTION <br /> 6 Tank-top containment sumps are free of water,debris,and hazardous substance. <br /> Note:Visual inspection o sums is only required in sums where an alarm has occurred in the past month for which there is no service record <br /> �• <br /> Sum Location: o 0 �' h ,• Y Sump Location: , . <br /> Sump Location: 1 Sump Location: <br /> 7 Spill containment structures are free of water,debris,and hazardous substance. <br /> Y N NA Y N NA <br /> Tank 1—Contents: Tank 3—Contents: <br /> Tank 2—Contents: Tank 4—Contents: _ <br /> 8 Under-di <br /> Lspenser containment areas are free of water,debris and hazardous substance. <br /> Y I N NA Y N NA <br /> Dispenser 1/2 Dispenser 7/8 <br /> Dispenser 3/4 Dispenser 9/10 _ <br /> Dispenser S/6 Dispenser 11/12 <br /> 9 Leak detection is properly located within under-dispenser containment. <br /> Y I N NA Y N NA <br /> Dispenser 1/2 Dispenser 7/8 <br /> Dis enser 3 14 Dispenser 9110 <br /> Dis enser 5/6 Dispenser 11/12 <br /> PAPERWORK INSPECTION _Y N NA DAT 11 DONE <br /> 10 Monitoring system certification has been coEMIcted within past 12 months. 8—;�6-fl <br /> 11 SecoaiLag containment tests have been completed within the required timeframe. T + `( <br /> 12 Spill containment structure(bucket)testing was Completed within the past 12 months. <br /> 13 Tank ti fitness testing was completed within re uired timeframe. - <br /> 14 Line tightness testing was completed within re uired timeframe. <br /> 15 Ocher required testin maintenance was completed within required timeframe. List test/maintenance items below. <br /> Test/Maintenance: <br /> Test/Maintenance: I YJ <br /> TestlMaintenance: <br /> :. jaa r�•Efifir= 'a ._p. - .ti.-:,`5 ":s" :�:T _„ r.,' C;;c e`.. -?S'„•, r: i•.Y.'+da,... <br /> FACILITY EMPLOYEE TRAINING Y N NA <br /> 16 Alt facility employees have received the ELX uired on-the-'ob trainin within the ast ear. __ <br /> 17 All facili a to hired within the 2ast 30 da have received the uired on-the-job 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 />