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N%.V 1%W01 UNDERGROUND STORAGE TANK SYSTEM DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT Facility Name: W7, $2t 9�r,�c inspection Date: � '.5' y o Facility Address: 7bf L,/, C/1ij,21�r,C Lt/}y CIty' J r H7 Name of Designated UST Operator Conducting Inspection: i'e foc International Code Council Certification No.: S2clsj-30 —JG Expiration Date: P ®&' Signature: Phone: ( )y d h ext. NIA-Not Appikable Item MONITORING PANEL/ALARM HISTORY Yes No N/A 1. I2each powered on and in pro r operating mode? 2. Inot currentl showin an leak alarms? 3. Iortflog for the previous month available,and has it been reviewed by the r? Attach a co o rhe alarm histo repo lito e ort/(o to this ins eclion orm. 4. evious month been res onded to a ro natel ! UST SYSTEMINSPECTION 5. Are tank-top containment sumps free of water,debris,and hazardous substance? Note:lijthe annrer to Item J was"Yes. skip to Item 6.Sumps where an alarm has occurred m the past month must be inspected,,if a qual�ed sem,"technicmn has not responded m, and o rl addressed.the cause o the alarm.Documematum ver, in to riate senre should be attached to this rert. Yes No I Yes No Sum Location: Sum Location: Sum Location: Sum Location: 6. Are s ill buckets containment structures free of water,debris,and hazardous substance? Yes No N/A Yes No N/A Tank 1 ID— Tank 4 ID— --� Tank 2 ID— Tank 5 ID— Tank 6 ID— Tank 3 ID— 7. Are under-dis eraser containment areas free of water,debris,and hazardous substance? y Yes No N/A es No N/A Dis enser-1/2 Dis nser-9/10 Dis enser-3/4 Dis — 11112 Dis Dis nser-5/6 Dis nser- 13/14 1 Li I Li Dis nser—7/8 Dispenser— IS/16 8. Leak detection is to erl located within undis nser containment. Y2 No N/A Yes No N/A Dis ser- 1/ — _ Dis enser-9/10 30. Dis enser-5/6 11 11 Dis enser- 13/14 Dis enser—7/8 Dis enser— 15/16 PAPERWORK INSPECTION Yes No N/A Da one 9. Monitorin S stem Certification was com leted within the past 12 months? / 10. Line Leak Detectors were tested/certified within the ast 12 months? It. S ill bucket containment structure testin com leted within thepast 12 months? 12. Line ti mess testing completed within the required time frame? 13. Secon containment tests completed within the required time frame? 14. Enhanced Leak Detection completed within the re tared time frame? 6 15. Other re uired testin maintenance was com Ieted within required time frame? List rest/maintenance items below. Describe Test/Maintenance: Describe Test/Maintenance. _ FACILITY EMPLOYEE TRAINING Yes No N/A 16. Have all facilit employees received the required on-the-'ob trainingwithin the past ear? 17. Have all facili em to ees hired within the ast 30 tla s received the re uired on-me-job training., Note: Explain any"No"answers in the"Comments"section on the following page.Those issues require corrective action from the UST owner/operator. 9/26105 UN-057-1/2 www.unidoes.org