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" n <br /> UNDERGROUND STORAGE TANK STEM <br /> DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT <br /> Facility[*Tame: InDate: <br /> i♦acility AdmCity: <br /> Name of Desi U Operator Conductin&Iospwtion: <br /> international Council Cextifisation Na: r-- EXP. tion:Date: <br /> Signature: <br /> Phone: ext <br /> NIA Not cable <br /> Item MONITORING PANEL I ALARM HISTORY a NIA <br /> 1. -is the monitoring stem powered on and in ro o eratin made?. x'11 <br /> 2, is the monitoring stem not currentl showing any leak alarms? <br /> 3. is the Alarm History Report/log for the previous month available,a$d has it been reviewed by the <br /> Desi ted USTOperator? Attach a ca a the alarm histo re ort/lo to this ins ectian orm. <br /> 4: Has each alarm for the previous month been responded to ro riatel ? <br /> F. h. r -„ <br /> UST SYSTEM IN'SPECT'ION{ <br /> 5. Are tank-top containment sumps free of water,debris,and-lha dourbsta cce? Note:Ifthe awwer to Item 4 was"Yes,,'skip <br /> to Item 6. 5umrps where an alarm has occwred In the past month mast beInspected' a ! ed service technician has not responded to,and <br /> ro r! addressed the cause a The alarm.Documentateon ri 'n o r. to service should be attached to this report. <br /> Ye` 00NO Yet No <br /> 47 <br /> Sump Location: Sump Location: <br /> Sump Location: Sum Location: <br /> 6. Ares ill"buckets containment structures free o ter'debris,and hazardous substance? Y No NIA <br /> Yes o NIA <br /> Tank 1 ID Tank 4 ID-- -0 1 El <br /> Tank <br /> D- <br /> Tank 2 ID- Tank 5 ID- <br /> Tank <br /> 3 ID- Tank 6 <br /> ID- <br /> 7. Are under-dispenser containment areas free of water debris,an does substance? Yes No NIA <br /> Yes I No NIA <br /> Dis nser- 112 Dis eraser-9/10 <br /> Dis enser-314 Dis enser - 11112 <br /> Dis nser-516 Dis enser -13114 <br /> Dis enser-7/S Di enser-15116 <br /> 8. Leak detection is Eggly located within under-dis enser.co ent. Yes No NIA <br /> 11 Yea No NIA <br /> Dis 112 Dis nser-9/10 711 El <br /> Dispenser.-314 Di enser- 1.1/12 <br /> LL <br /> Di nser-5/6 Di nser-13114 <br /> Di nse Dis enser-15116 <br /> PAPERWORK INSPECTIONYes o NIA Date Done <br /> 9. Monitoring System Certification was completed within theast 12 months.? <br /> 10. Line Leak Detectors were tested/certified within the past 12 months? <br /> 11. Spill bucket containment structure tesi completed within the past 12 months? ZOOS <br /> 12. Line ti tness testing completed within the required time frame? <br /> 13. Secondary containment tests completed within the required time frame? <br /> —i—4. Enhanced Leak Detection com leted within the reqaired time frame? <br /> 15. Other required test' maintenance was completed within nuired time frame? Dst testlmaintenanee i ms below. <br /> Describe Test/Maintenanee: 10 1 <br /> Describe Test/Maintenance: <br /> ]:r. f�°- a r- _:i r''?:f-•+,- F-';:.., r ;,.'",�.,+ a:. i..f'° .•..`7. <br /> FAG'II,IT1'EMPLOYEE TRAINING Yes o NIA <br /> 16. Have all facility em to ees received the required on-the-job training within the pastyear? <br /> =Have all facili em 10. 2 e hired within the past 30 days received the required on-the-`ob train-- <br /> Note: Explain any'No"answers in the"Comments"section on the following page.Those issues require corrective action om <br /> the UST owner/operator. <br />