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N.. ..i <br /> UNDERGROUND STORAGE TANK SYSTEM <br /> DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT <br /> Facility Name: u Inspection Date: <br /> R ylrt2cti ie <br /> Facility Address: MP `" City' <br /> Name of Designated UST Operator Conducting Inspection: A2Ji�f� , iray�' <br /> International Code Council Certification No.: 1P�bS-3�_UG Expiration Date: l <br /> Signature: Phone: (,�Uu�/fl (�ff.y6/ ext. <br /> 77"` N/A=Not Alseliabile <br /> Item MONITORING PANEL/ALARM HISTORY Yesl No N/A <br /> 1. Is the monitoring s stem powered on and in proper operating mode? <br /> 2. Is the monitoring astern,not currently showing any leak alarms? <br /> 3. Is the Alarm History Report/log for the previous month available,and has it been reviewed by the <br /> Designated UST Operator? Attach a co o the alarm histo re art/lo to this ins ection orm. <br /> 4. Has each alarm for the previous month been responded to a ro riatel ? <br /> Li <br /> UST SYSTEM INSPECTION <br /> 5. Are tank-top containment sumps free of water,debris,and hazardous substance? Note if the annver to Item{was ')es. skip <br /> to Item 6. Sumps where an alarm has occurred in the past month must be inspected f a quaked service technician has not responded to, and <br /> ro rl addressed,the muse of the alarm.Documentation wrif)4ng appropriate service should be attached to this"port <br /> Yes No Yes No <br /> Sum Location: Sump Location: <br /> Sum Location: Sum Location: <br /> 6. Area ill buckets containment structures free of water,debris,and hazardous substance? <br /> Ye No NIA Yes No NIA <br /> Tank 1 ID— Tank 4 ID— <br /> Tank 2 ID— Tank 5 ID— <br /> Tank 3 ID— 1 1Tank 6 ID— <br /> 7. Areunder-dis enser containment areas free of water,debris,and hazardous substance? <br /> Yes No N/A Yes No N/A <br /> Dis enser-1/2 Dis enser-9/10 <br /> LL, Li Li <br /> Dis nser—3/4 Dis enser— 11/12 <br /> Dis nser—5/6 Dis nser—13/14 <br /> Dis nser-7/8 Dis enser- 15/16 <br /> 8. Leak detection is ro erly located within under-dis nser containment. <br /> Yes No N/A I Yes No N/A <br /> Dis enser— Dis enser-9/10 <br /> TO—AdK -me <br /> Dis enser-5/6 1,ADis enser— 13/14 <br /> Dis enser—7/8 Dis enser— 15/16 <br /> PAPERWORK INSPECTION Yes ftamteaceye <br /> 9. Monitorin S stem Certification was completed within the past 12 months?I0. Line Leak Detectors were tested certified within the ast 12 months?11. S ill bucket containment structure testin con leted within the est 12 months?12. Line ti mesa testin coin leted within her uired time frame? <br /> 13. Second containment tests con leted within the re uired time frame?14. Enhanced Leak Detection con leted within there uired time frame?15. Other re uired testin maintenance was con leted within re uired time frame? List test/m <br /> Describe Test/Maintenance: <br /> EJ I <br /> Describe Test/Maintenance: <br /> FACILITYEMPLOYEE TRAINING Yes I NoN/A <br /> 16. Have all facilit em to ees received the required on-the-job trainin within the ast ear? <br /> 17. Have all facilit em to ees hired within the past 3o da s received the re uired on-the-ob treinin .? <br /> Note: Explain any"No"answers in the"Comments"section on the following page.Those issues require corrective action from <br /> the UST owner/operator. <br /> UN-057-1R <br /> www.unidocs.org 9/26/05 <br />