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09/29/05 09:42 FAX 925 422 2748 EPD / WGMG Q012 <br /> Designated Underground Storage Tank(UST)System Operator <br /> Monthly Visual Inspection Checklist <br /> Facility Name: Jf '500 88 Date: <br /> -) 9 <br /> Facility Address; C'e'-r-b'I " <br /> t6/),2d <br /> City: - I 0-0-c-V . q <br /> Designated UST O erat Conducting9 <br /> the Inspection: /-J,-I' f- <br /> ICC cert.#: �tq 5-?1 K-U C ExpDate: i-1//Z/e) <br /> Signature: Phone: <gr-?-6-- IA;z­0 <br /> Y=Ye N-No NA=Not Applicabte <br /> Item# MONITORING PANEL/ALARM HISTORY Y N NA <br /> R. <br /> F 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 /> Desi ted UST Qperator. Attach a cqgy ofthe alarm histo Lepart ltqgto this inEectionLorm.) <br /> 4 Each alarm for the previous month has been responded to appKoately. <br /> L <br /> 5 Sensors located in tank-top containment suMps have not alarmed in the past month. K I I <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 /> addressed,the cause of the alarm.Documentation verifying appropriate service should be attached to this report. <br /> inspection is re fired,results <br /> pff-super'p should be recorded in item 6.below. <br /> q,, ' <br /> UST SYSTEM INSPECTION <br /> 6 Tank-top containment sumps are free of water,debris,and hazardous substance. <br /> Note:Visual ins ection ofsum ps is only required in sum ere an alarm hasoccurredin the past month or which there is no service record <br /> Y N Y N R <br /> Sump Location., Sum Location: <br /> Sump Location: <br /> Sum Location: <br /> 7 Spill containment structures are free of water,debris,and hazardous substance. <br /> Y N NA Y N NA <br /> Tanki-Contents: Topwttik X I Tank 3-Contents: <br /> Tank 2-Contents: I 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 /> Dip eraser 1 2 Dispenser 7/8 <br /> Dispenser 3 4 Dispenser 9/10 <br /> Dispenser 5 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 112 Dispenser 7/8 <br /> Dispenser 3/4 Dispenser 9110 tl <br /> Dispens r 5/6 ispenset 11/12 <br /> PAPERWORK INSPECTION INSPECTION Y I N NA DATE DONE <br /> 10 Monitoring system certification has been completed within past 12 months. <br /> 11 Secondary containment tests have been completed within the re sired timeframe. A, -0V <br /> 12 SRi11 containment structure(bucket)testing;was completed within the past 12 months. X_ G-0 St <br /> 13 Tank tightness testing was comple A within required timeframe. <br /> 14 Line tigfitness tes!!u was completed within required timeframe. <br /> 15 Other Leauired testing/maintenance was completed within rSquired timeframe. (List est/maintenance items below.) <br /> Test/Maintenance. <br /> Test/Maintenance: <br /> TestlMaintenance: <br /> n <br /> FACILITY EMPLOYEE TRAINING Y N NA <br /> 16 -1 All facility employees have received the d on-2njob training within the past year. <br /> yees hired within the past 30 dM have received 9 LA <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 />