Designated Underground Storage Tank (Ust) Operator Monthly Visual Inspection Checklist Page 2
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3Designated Underground Storage Tank (UST) Operator
Monthly Visual Inspection Checklist
Facility Name:
Date:
Facility Address:
City:
Zip Code:
Designated UST Operator Conducting the Inspection:
International Code Council Certification #:
Expiration Date:
/
/
Signature:
Phone: (
)
Y = Yes, N = No, NA = Not Applicable
Item
MONITORING PANEL / ALARM HISTORY
Y
N
NA
1
Monitoring system is powered on and in proper operating mode.
2
Monitoring system is not currently showing any alarms or warnings.
3
Alarm history report/log for the previous month is available, and has been reviewed by the
Designated UST Operator. (Attach a copy of the alarm history report/log to this form if available.)
4
Each alarm for the previous month has been responded to appropriately.
5
Sensors located in tank-top containment sumps have not alarmed in the past month.
5a
-
List all tank-top sumps where alarms occurred in the past month: _____________________________________
__________________________________________________________________________________________
Note: Sumps where an alarm has occurred in the past month must be inspected unless a qualified service technician responded to, and
properly addressed, the cause of the alarm. Attach documentation verifying appropriate service to this report.
If sump inspection is required, record results in item 6, below.
UST SYSTEM INSPECTION
6
Tank-top containment sumps are free of water, debris, and hazardous substance. Sensors are located properly.
Note: Visual inspection of sumps is only required in sumps where an alarm has occurred in the past month for which there is no service record.
Y
N
Y
N
Sump Location:
Sump Location:
Sump Location:
Sump Location:
Sump Location:
Sump Location:
7
Spill containment structures are free of water, debris, and hazardous substance.
Y
N
NA
Y
N
NA
Tank 1 – Contents:
Tank 3 – Contents:
Tank 2 – Contents:
Tank 4 – Contents:
8
Under-dispenser containment areas are free of water, debris, and hazardous substance. Sensors are located properly.
Y
N
NA
Y
N
NA
Dispenser 1 / 2
Dispenser 9 / 10
Dispenser 3 / 4
Dispenser 11 / 12
Dispenser 5 / 6
Dispenser 13 / 14
Dispenser 7 / 8
Dispenser 15 / 16
PAPERWORK INSPECTION
Y
N
NA DATE DONE
9
Monitoring system certification has been completed within past 12 months.
10
Secondary containment tests have been completed within the required timeframe.
11
Spill containment structure (bucket) testing was completed within the past year.
12
Tank tightness testing was completed within required timeframe.
13
Line tightness testing was completed within required timeframe.
14
Other required testing/maintenance was completed within required timeframe. (List test/maintenance items below.)
Test/Maintenance:
Test/Maintenance:
Test/Maintenance:
FACILITY EMPLOYEE TRAINING
Y
N
NA
15
All facility employees have received the required on-the-job training within the past year.
16
All facility employees hired within the past 30 days have received the required on-the-job training.
Note: Any answer of “N” should be explained in the comment section on the following page, and will require
follow-up action.
Page 1 of 2
November 2004
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