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09/29/05 09:43 FAX 925 422 2748 EPD / WGNG IA 014 <br /> Designated Underground Storage Tank(UST)System Operator <br /> Monthly Visual Inspection CheckHst <br /> -FacilityName: S,jc 36Q g8.2_I Date: V,?-t)k-I- <br /> -Facility Address: Carr-ml/ tjaL1a,_o 1�cj <br /> -City, Zip Code: 57 <br /> -Designated UST O for Conductin the Ins action: &InA 1 )rJ V <br /> ICC Cert. e'ic_ I W.Date:4# /(7 106 <br /> Signature: Phone: qp,5-- A <br /> —ot 6 7 <br /> Y—Yes,N—No, A=Not A Ucable <br /> Item# MONITORING PANE L I ALARM 1=ORY -Y NA <br /> I Moni!2n�n system is powered on and in plMer 2pgs#M mode. <br /> 2 Monitoring sem 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 aced UST Operator. LAttach a co a 9 X <br /> the alarm histo re I a this ins E�ary port/to t <br /> 4 Each alarm for thep!E Lous month has been responded to appropriately. <br /> 5 Sensors located in tank-top containment sumps have not alarmed in the past jnonth. <br /> 5a List all tank-top sumps where alarms occurred in the past month: 9,t,;t V <br /> Mote:Sumps where an alarm has occurred in the past month must be inspected unless a qwali6edservice technician responded to,and <br /> property addressed,the cause of the alarm.Documentation verifying appropriate service Aould be attached to this report. <br /> suW fns ection is red,results should be recorded in item 6.below. <br /> sire A <br /> UST SYSTEM INSPECTION <br /> 6 Tank-top containment sumps are free of water,debris,and hazardous substance. <br /> xate, nival inspection ofsymps is on i rmequ aired In sumps where an alarm has occurred in Aw EEt month f <br /> or which there is no service record <br /> Y I N Y N <br /> Sump Location: SZ Location: <br /> S <br /> Swnp Location: oc <br /> Location: <br /> ump Location: <br /> 7 Spill containment structures are free of water,debris,and hazardous•substance. <br /> Y N NA JYJ N NA <br /> Tank I—Contents: Tank 3—Contends: <br /> Tank 2—Contents: Tank 4—Conteno: <br /> 8 Under-dispenser containment areas are free of water,debris,and hazardous substance. <br /> Y N NA Y N NA <br /> Dispenser 112 Dispenser 7/8 <br /> Dispenser 3/4 Dispenser 9110 <br /> Dispenser 5/6 Dispenser 11/12 <br /> 9 Leak detection is properly located within under-dispenser containment. <br /> Y I N INA Y I N NA <br /> Dispenser 1 2 Dispenser 7/8 <br /> D 4penser 9 <br /> kpenser 3 4 D <br /> 99enser 5 6 =enser 11 12 <br /> .. ......... <br /> PAPERWORK INSPECTION Y N NA DATE DONE <br /> 10 Monito!!!!jj system certification has been completed within past 12 months. X .1iTo <br /> 11 Seco ndwy containment tests have been completed within the Muired timefimme. T-/u, <br /> 12 §RiU containment structure(bucket testing was coppleted within the past 12 months. X <br /> 13 Tank fightness testin was com lctsd within E2M4!Rd timeframe ' I <br /> 14 Line ti mess testing was c2Mleted within n!qu _ vc I <br /> nixed tim-efiame. <br /> 15 Other required testing/maintenance was co feted within Muired timeframe. (List test/maintenance items below. <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> 'sgg'Fmm—lY mg <br /> FACILITY EMPLOYEE TRAINING 1Y1 N INA <br /> 16 All facility eTployees have received the regRul-ed on-the job t!�within ffhe past year. <br /> 17 All facility employees hired within the past 30 days have received the req!!kod on-the-job training. I I _A, <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 />