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UNDEktROUND STORAGE TANK SYSTEM <br /> DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT <br /> Facility Name: <br /> t)vi1 f7 e9-c. IRspee:tion Date: <br /> Facility Address: l <br /> `� S Wl �J-{•fx�t i City: /,, <br /> Name of Designated tJS"f Operator Conducting Inspection: - <br /> International Cale Cnuru:il Certific;ttion No.: �.1y �" /6110 ---= <br /> _ 6_ � Expiration Date:// <br /> Signature: --- --__. <br /> Phone: (//p'&vkilt. <br /> ItemWA:Not AppileaW <br /> MONITORING PANEL/ALARM HISTORY Yes No N/A <br /> 1. Is the monitormg system powered on and inproper operating mode° <br /> 2, is the mtmitonn s stem not wrrentl showm an leak alarms? <br /> 3. Is the Alarm History Rcport/Iog fur the previous ntcmth availably,and has it been reviewed by the <br /> Desi mated ITS rator't (Attach a cu v o the alarm history repnrtAag to this inspectk>a irrm.) i t <br /> 4. Has each alarm!br the vious month bren re rrded to a o riatel ? <br /> U.ST SYSTEM INSPECTION <br /> 5. Are tank-top containment sumps Gee of wateq debris.and hazardcws substanxe? wHr:1/nlrnn.�wer 1,.hrnl a.n, ••Yr,,-,1;; <br /> to hem 6. Sxrxps nllrrr all ldtrrm Aos w•rurrrd 4i Mr pllsr nurrclF mn�t Lr a1,rylnYrd iJa yllatejird rrrvice rerlarfcion iras mx rrq+ulldrJ 11•, aryl <br /> agrrh-uddresarel,Ikr rrtxce 1d1Ar nlnml 7kwwmrruMilm lr.i iia a n, rally.wmue.c6o, Ar lato.dlrJ A)dlu rr a <br /> Yes No Yes No <br /> Sum Location_ Sump Location: <br /> Sum L Ovation: Sump Location: ' '— <br /> G. Are s ill buckets(containment structures)free of water,debris,and hazardous substance? <br /> Yes No N/A Yes No N/A <br /> Tank 1 ID-- I Tank 41D- �_. <br /> tank21D ` ,_--- - Tank 5IDITT <br /> - <br /> Tank 3 W- Tank 6 ID- <br /> 7. Are under-dispenser containment areas free of water,debris,and hazardous substance? <br /> Yes No N/A yes No I N/A <br /> Dispenser- lr_ 0E] FD poser-9/10 <br /> Dispenser-3/4i• nser-. 11/12 <br /> Dispenser-S/610 Dis nser- 13/14 <br /> Dispenser-7/8 Dis nser- 15/16_ <br /> 8. Leak detection is propuly located within under-dis user containment. <br /> Yrs I No I N/A I Yes No N/A <br /> Uis mer__I12Uis nser-9iloI El <br /> Dis Nnser-314^ 1Dispenser 11112 _ <br /> Dis nset -516 Dis poser- 13/14 <br /> Dispenser -7/8I &I W I LJ I Uis nser- 15116 -----_�--- <br /> ____ PAPERWORK INSPECTION I'm I No N/A to Done <br /> 9. Monitonn System Certification was completed within the past 12 months? Of� <br /> 10. Litre Leak Detectors were testedlcertified within the past 12 months? C1 Y,W06 <br /> 11. Spill bucket(containment structure)testing completed within the past 12 months? LJ %filet, <br /> 12. Line lightness within the required time frame? <br /> 13. Secondary containment tests completed within the required time frame? 0 Eli <br /> ky_ <br /> 14. Enhanced Leak Detection completed within the required time frame? 0 El <br /> 15. Other required testingfirtaintenance was completed within r-aired time frame? List testhtlaiaterlance items below.) <br /> r Describe Test/M_aintenance: <br /> Describe l est/Maintenance; <br /> FACILITY EMPLOYEE TRAINING _ Y I No I N/A <br /> 16. Have all facility employers received the roquired nn-the job training within the past year? <br /> 1.7. 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 US f ownerioperav-o <br />