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09/29/05 09:44 FAX 925 422 2748 EPD / WGMG 0016 <br /> Designated Underground Storage Tank (UST) System Operator <br /> Monthly Visual Inspection Checklist <br /> Facilit�ame: _&j fe 3 05 A")- ReA, _Date: 75-3 <br /> -Facility Address:Cft,,j,,c*f Ll I <br /> Ci Zi—7 rv,,el Zip Code: <br /> -Designated UST Operafor Conducting the Inspection: 4 <br /> ICC Cert.#: -S:Xys"7 f is­kc, :J�x Date: /I/t t, 1,oX <br /> Phone: C12T-,4Z7-0/.K9 <br /> Y Yes N=No,NA=Not AppBeable <br /> Item# MONITORING PANEL/ALARM HISTORY Y N NA <br /> `77 VF <br /> &MA <br /> I Monitoring system is powered on and in vr2LYer operating mode. X1 <br /> 2 Monitoring§jstem is not currently showing an leak alarms. <br /> 3 Alarm history report/log for the previous month is available,and has been reviewed by the <br /> Designated UST 1`1--f—. Attach a co o the alarm history report/to to this ins pectionform) <br /> 4 Each alarm for the previous month has been responded to 2ppjREnLately. <br /> 5 Sensors located in tank-top containment sumps have not alarmed in the past month. <br /> 5a List all tank-top sumps where alarms occurred in the past month: A14,.,, r,,, 1;r Sf <br /> 4Ait <br /> Note:Sumps where an alarm has occurred in the past month must be inspected unless a qualified service technician responded to,and <br /> properly addressed,the cause of the alarm.Documentation ver6ing appropriate service should be attached to this report. <br /> QuMction is P ins aired,results should be record " . - :, - <br /> below. <br /> UST SYSTEM INSPECTION <br /> 6 :[ank-top containment sumps are free of water,debris,and hazardous substance. <br /> _ <br /> Note: Visual inspection of sumps Is only requi in summps where an alarm has occurred in the post month or which!here is no servict,record <br /> w <br /> Y N Y <br /> Sump Location: <br /> Sump Location: X <br /> Sump Location: Sump Location: <br /> F7 Spill containment structures are free of water,debris,and hazardous substance. <br /> e, f <br /> j.,r--/Te Y N NA Y N NA <br /> Tank I-' Contents:L,,4-,J j Q leg,;/- X, 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 N NA Y N NA <br /> Dypenser 1 2 Dispenser 7/8 <br /> Dispenser 3 4 Dis <br /> penser 9110 7— <br /> Dispenser 5 6 Dispenser 11/12 <br /> 9 Leak detection is properly located within under-dispenser containment. <br /> Y N NA Y N NA <br /> 2Lseenser I/2 Dis enser-718 <br /> _2isEenser 3/4 Dispenser 9110 <br /> Dispenser 5/6 Diseenser 11 12 <br /> ----------- �;7 <br /> PAPERWORK INSPECTION Y I N INA DATE DONE <br /> 10 Monitoring system certification has been completed within past 12 months. q&,/ <br /> 11 Secondary containment tests have been completed within the zequired timeframe. q L <br /> 12 Svill containment structure(bucket)testis&was co feted within the past 12 months. <br /> 13 Tank tightness testing was completed within reguired timeframe. <br /> 14 Line tightness testis g was c2MIeted within required timeframe. JrA <br /> 15 Other required testis maintenance was completed within required timeframe, (Listtest/maintenance items below.) <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> ThWM,aintenance: <br /> FACILITY EMPLOYEE TRAINING <br /> Y N NA <br /> 16 All facility STployees have received the required on-the-'ob training within the past year. <br /> 17 All facili em tos hired within the post 30 do have received the reg_uired on-thejob training. <br /> Note: Any answer of'IN"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 />