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V*.. •.i <br /> UNDERGROUND STORAGE TANK SYSTEM <br /> DESIGNATED U 'S,,T,,rr OPERATOR MONTHLY INSPECTION REPORT <br /> Facility Name: 7/LY Yt ri2f1f7 Inspection Date: 2 ',Tb) <br /> Facility Address: 12g G/, �sfghlse (✓ City: .C-jACX_Y� <br /> Name of Designated UST Operator Conducting Inspection: <br /> Intemational Code Council Certification No.: S36—t✓L Expiration Date: <br /> Signature: Phone: W )q/d_-y9,I/ ext. <br /> NIA=NotA licable <br /> Item MONITORING PANEL/ALARM HISTORY Yes No I N/A <br /> 1. Is the monitoring system powered on and in proper operating mode? <br /> 2. Is the monitoring system not currently showmp 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 rotor? Attach a copy o the alarm hislo2 report/logreporillog to this inspection orm. <br /> 4. Has each alarm for the previous month been responded to a ro riatel ? <br /> 11711 Li <br /> UST SYSTEM INSPECTION <br /> 5. Are tank-top containment sumps free of water,debris,and hazardous substance? Note:tjthe ansrer to lie.a was "i'es,"skip <br /> to Item 6.Sumps where an alarm has occurred in the past month must be inspected ilia qualified service technician has not responded to.and <br /> a rl addressed.the cause o the alarm.Documentation vers in a ro riare service should be attached to this"port. <br /> Yes No Yes No ' <br /> Sum Location: - Sum Location: <br /> Sum Location: z Sum Location: <br /> 6. Are s ill buckets containment structures free of water,debris,and hazardous substance? <br /> Yes No N/A I YesNo N/A <br /> Tank 1 ID— Tank 4 ID— 101 <br /> Tank 2 ID— Tank 5 ID— <br /> Tank 3 ID— Tank 6 ID— <br /> 7. Are under-dis enser containment areas free of water,debris,and hazardous substance? <br /> Yes No N/A Yes No I NIA <br /> Dis enser— 1/2 Dis enser-9/10 <br /> Dis enser-3/4 Dis ser- 11/12 <br /> Dispenser—5/6 _-13/14 Lj <br /> Der- 15is nser-7/8 s /16 <br /> 8. Leak detection is roverly located within under-disenser containment. <br /> Yes No N/A Yes No NIA <br /> Dis nser— l/ Dis nser—9/10 <br /> TD—ALq 'nip _.«, / „ , . . . .9 a► <br /> Dis nser—5/6 Dis enser— 13/14 <br /> Dis enser-7/8 Dis enser- 15/16 <br /> PAPERWORK INSPECTION Yes No N/A I Dati Done <br /> 9. Monitorin S stem Certification was com leted within the past 12 months? o I bt <br /> 10. Line Leak Detectors were tested/certified within the past 12 months? 1� <br /> 11. S ill bucket containment structure testin com Ieted within the past 12 months? <br /> 12. Line ti mess testingcompleted within there uired time frame? <br /> 13. Secon containment tests completed within the re uired time frame? <br /> 14. Enhanced Leak Detection com leted within[he re aired time frame? �I I <br /> 15. Other re uired testinalmnintenance was com leted within reuired time frame? List test/maintenance items below. <br /> Describe Test/Maintenance: <br /> Describe Test/Maintenancc: .. <br /> FACILITY EMPLOYEE TRAINING Yes No N/A <br /> 16. 1 Have all facilit employees received the re uired on-the-job tra ning within the past year, W Li <br /> 17. 1 Have all facility employees hired within the past.30 days received the required on-the-job training.? <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-057-1/2 www.unidoes.org 9R6/OS <br />