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09/29/05 09:41 FAX 925 422 2748 EPD / WGMG 0010 <br /> Designated Underground Storage Tank(UST)System Operator <br /> Monthly Visual Inspection Checklist <br /> Facility Name: 4,4A//, 5,/-e 1806 <br /> aV I Date; R1. <br /> Facility Address: C&rl' l Ror-w <br /> City: - I Zip Code: 4?6­3 7 6 <br /> Desi ted UST Operatol Conducting the Ins ection: V,Q q 0 re` 4 <br /> ICC Cert.#: 6- 71 8'y:.j c ERAYate: /7/ /Q 6 <br /> Signature: Phone: qzs---1.2 2--0 16 1? <br /> Y-Yes,N—No. A=Not ApjPlivable <br /> Item# MONITORING PANEL/ALARM HISTORY Y N NA <br /> 'L�MIR7�7_'ctj <br /> I Monitoring system is powered on and in ppper operating mode. yl_ <br /> 2 Monitoring systeal 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 /> Desi ted UST Operator. (Attach a ncpy of the alarm histo?y re I g to this!Meection form.) <br /> port/ o <br /> 4 Each alarm for the previous month has been MTonded to!peMriately. 4- <br /> 5 Sensors located in tank-top containment sumps have not alarmed in the past month. <br /> Sa 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 /> property addressed,the cause of the alarm.Documentation verifying appropriate service should be attached to this report. <br /> II sum inspection is required,results should be recorded in item 6,below. <br /> --------- ..... t. 'd - I - <br /> -P -M=11V1_1 <br /> UST SYSTEM INSPECTION <br /> 6 Tank-top containment sumps are free of water,debris,and hazardous substance. <br /> Note:Visual inspection of sumps is only re uired in sumps where an alarm has occurred in the past month or which there is no service record <br /> Y N Y N <br /> Sum p Location: T- <br /> q;� a42jjr Sum e Location: <br /> Sump L Sum Location: <br /> 7 Spill containment strictures are free of water,debris,and hazardous substance. <br /> Y N NA Y N NA <br /> Tank I-Contents: I f-Y Tank 3-Contents.- <br /> Tank 2-Contents: AK Tank 4-Contents: <br /> 8 Under-dispenser containment areas are free of water,debris,and hazardous substance. <br /> Y I N NA Y N NA <br /> D4penser 112 D!Venser 7/8 <br /> Dispenser 3 4 &�penser 9/10 <br /> DisK <br /> ,penser 5 6 K DYR!nser 11/12 <br /> 9 Leak detection is properly located within under enser containment. <br /> Y N NA Y N NA <br /> Dispenser 1 2 Y, Dispenser 7/8 K <br /> Dispenser 3 4 Y- Dispenser 9/10 le <br /> Dispenser 5 6 )L Dispenser 11/12 <br /> PAPERWORK INSPECTION Y I N INA DATri,DONE <br /> 10 Monitoring system certification has been co Tete I within past 12 months. 4, <br /> 11 Secondary containment tests have been completed within the required timeframe. SC =G-fly <br /> 12 Spill containment structure(bucLet)testing was co!!!Rleted within the past 12 months. X <br /> 13 Tank tightness testing was completed within Muired timeframe. <br /> 14 Line tightness testing was c"m feted within required timeframe. <br /> 15 Other required testing/maintenance was co!npfeted within reu timeframe. t <br /> q-ired tim fra . (Listtest/maintenance items below. <br /> Test/Maintenance: I I <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> FACILITY EMPLOYEE TRAINING Y N NA <br /> 16 1 All facility eTployees have received therequired on-the-job training within the past year. <br /> 17 Ail facility employees hired within the pat 30 days have received the!!T8MA on-the-job training. <br /> Note: Any answer of"N"should be explained in the comment section on the following page,and will require <br /> follow-tip action from the UST owner/operator. <br /> Page 1 of 2 <br />