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Cash Mine and Who-Do Mine <br />1. ABOVEGROUND STORAGE TANK MONTHLY VISUAL <br />INSPECTION FORM <br />Facility name Inspection <br /> Date <br />Street address City ZIP <br />(Ise either this form or its equivalent to document monthly visual inspections required by §3-5 of Colorado's <br />Storage Tank Regulations. Keep these records at least 12 months However, it is advisable to keep records <br />indefinitely, since they may be required as part ojthe compliance review concerning a claim for <br />reimbursement rom the Petroleum Stora a Tank Fund <br />1. Visible leaks on tanks, tank seams, connections, fittings or valves? ^ No ^ Yes <br />If "yes," identify tank & describe leak. Record action taken to correct problem and date done. <br />2. Visible leaks on aboveground piping, pipe seams, connections, fittings, flanges, threaded connections, <br />pumps or valves? ^ No ^ Yes <br />If "yes," identify & describe leak. Record action taken to correct problem and date done. <br />3. Is overfill prevention equipment in good operating condition? ^ No ^ Yes ^ Not applicable <br />If"no," identify tank. Record action taken to correct problem and date done. <br />Ver fy operation of overfill prevention equipment according to the equipment manufacturer's instructions. <br />Verb operation of audible alarm if it can be tested. <br />4. If double-walled tank: <br />A. TS interstice free of liquid? ^ No ^ Yes <br />If "no," identify tank. Record action taken to correct problem and date done. <br />B. [s interstitial monitoring equipment operating properly? ~ No ^ Yes ^ Not applicable <br />If "no," identify tank. Record action taken to correct problem and date done. <br />Verb operation of interstitial monitoring equipment according to the equipment manufacturer's instructions. <br />5. Secondary containment system tree of tank product or other liquids/debris, such as rainwater, <br />snowmelt, dirt, leaves, trash, etc.) ^ No ^ Yes ^ Not applicable <br />If "no," identify tank. Record action taken to correct problem and date done. <br />6. Are concrete surfaces and ground free of any evidence of new leakage or spillage? O No ^ Yes <br />If "no," describe. Record action taken to correct problem and date done. <br />Appendix 1 dwugh 3 <br />