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13:57 FROM:TRRCY T & AUTO S 1209e325307 46e3433 P.17 <br /> Designated Underground Storage Tank (UST) Operator <br /> Monthly Visual Inspection Checklist <br /> f FaCility Na V A- <br /> Facility Address: <br /> Ci!y: <br /> ,Desi lsated UST Operator Conducting the fns <br /> International Io Coon;i)C ftcation#:, EXgiration Date: <br /> Si re: <br /> Item MONITOR)NG PANEL R <br /> ALAM HISTORY Yft YMN=NO%p -Applicable <br /> I I Monitoring system is N_ NA <br /> Powered on and in proper 2perating mode. <br /> 2 Monitorin stem is not—currently sho . an alarrns or w4min <br /> s. <br /> 3 Alarm history repormog for the previous month is available,and has been reviewed—b—ythe <br /> Desi - ated UST Operator. (Attach a copy!gthe alarm history reportl7o to this ortn ifavaiLghlo I <br /> 4 1 Each alarm for the pLevious month has been rusponded to approeriately. <br /> 5 A Sensors located in tank-to l)containment Sumps have not alarmed in the past month. <br /> List all tank-top sumps where alarmsoccurred in the past month: <br /> Note:SuP)tw where 0),alarm has otrwrodin Acpavt month must be Wpededunle&a qualified service zechnkian responded to, <br /> PrOPP*addressed the ram"'Offhc alarm.'41ach d0cwnsniNsun Mtftappropriatappropriate Service 1 ins ce to report Ord <br /> cdon is uired record results In i1cm 6.below. <br /> UST SYSTEM TNSPEMON <br /> 6 Lrank-top containment sumps are free of water,_debris,Note and hazardous substance. Sensors are located proper]y. <br /> 0 1 is mWm where=alarm has oxwredin the month or whiClt there iS»o service record <br /> 4, N <br /> Sum Location: <br /> tP Sum- <br /> : P Sum Location:I <br /> Sum p Locatim:ii <br /> Slum Location; I F <br /> Sum p Location: f-t- <br /> 7 S HI containment stru.�res are free or water debi <br /> and.hazardous substance. �J OT- <br /> NAW V <br /> Tank I Conle"Is., Tank 3-Contents: T <br /> 1� Tank 2-Contents.- Tank 4-Contents: <br /> 8 Under-dis enser­ COA-miuranit areas are tree of water debris,and hazardous substance-—Sensors are located ro erl <br /> Dispenser 112 V N NA D' enser 9/1 D <br /> Y N NA <br /> Divenser 3 4 Dis enser 11/ <br /> P" <br /> vy enser 13/14 <br /> Di enser 7 8 D' enser J5116 <br /> PAPERWORK IN Y N NA DATE DONE <br /> SfE�CTJON <br /> _9 1 MonitDrmiz Svslcm cerfific Jon has been completed withinpast 12 months—. <br /> 10 1 Secondary containment tests have beencompleted within the re wired timeframe. <br /> 11 Wll containment structure(bucket testing was completed within the <br /> Tank ti ------- __­ o E was cfeted within required timeframe. Past year. <br /> 12 - �m <br /> ii Line ti htnesa tpatin�.­s completed within required timeframe' <br /> 14 Other rNuired Lqgting/maintenaace was comelated within re uircd timeframe. is(restli aintenance <br /> .TjSJ1Lf_j_#------ <br /> - below_ <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> FAULITY EMPLOYEE TRAWING Ir N NA <br /> 15 1 All facil;tv emplqyces have reucived the reguired on-tbeJob training within the <br /> 16 JAll..racJJ past ear. <br /> ity em hired the ML49_-da s have received the reguired on-the-job training. <br /> Note: Any answer of —should he explained in the comment section OB the following page,and will require <br /> follow-up action. <br /> Page I of 2 "2 <br /> September 2004 <br />