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UNDERGROUND STORAGE TANK SYSTEM <br /> DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT <br /> Facility Name: r �_ Inspecliao Date: 'j7- <br /> Fuility Address: L7 l r!. i- _ Clty '7t. <br /> Warne of Designated ( Operator Conducting Inspection: <br /> Intemationat Code Council Certification No.: �O Expiration Date: / <br /> - -__-.—. - Phone: ezt. <br /> Signature /• (/�'.�yiG'�1�� <br /> WA=fwaApplicable <br /> Item MONITORING PANEL(ALARhI HISTORY Yes No N/A <br /> 1. is the monitorin,sxstem powered on and in proper operating mode'? <br /> 2 Is the monitoring system not�currently showin any leak alarms? <br /> T Is the Alarm History ReportAog for the previous month available,anal has it been reviewed by the <br /> Desi nate(l US"COperator? (Artach a -o Ly o rhe alarm histQD rej)oilAng m this inspecnnn nnn.i <br /> 4_ Has each alarm for the previous month been res tided to tatcl ? ja J.1 <br /> LIST SYSTEM INSPECTION <br /> 5. Are tank-top containment sumps tree of water,debris,and hazardous substance? N,4e lulu w.,wvr u,Item a nus "re...-.d:y, <br /> w nrm 6. Swop.,when w,alarm havwcurmd in!hr pu.t nwwh must Ar miperled iia yualifeed wmire!er'Mtrtam ha+n myxmded w,and <br /> n +ir rddmnsed,the ransr r !Nr o/nmt./hAvnuNmum vrri -in n a wtr wm4ntiluw4(Ge wua'hrd In lhia m rrl. <br /> Yes.i No <br /> Sum Ukation: Sump Location: <br /> - - Su <br /> Su Lcearion: m Location!.�...---. <br /> 6. Are s ill buckets(containment structures)free of water,debris,and hazardous substance? <br /> Yes No N/A Yes No N/A <br /> 'rank 1 ID- Tank 4/D- _ <br /> .. l'an� Tank S ID- <br /> Tank 3 ID- yank 6 ID- <br /> 7. Are under d user containment areas tree oiwater.debris,and hazardous substance? <br /> Yes No N/A Yes No N/A <br /> •nset-.� - <br /> Dis riser-9110 <br /> Dis riser - 3/4 _ Dis riser - 11112 <br /> DIS •user-516 Di. nser-- 13114 _ U- <br /> detection <br /> Di nser-7/8 Dispenser- 15/16,---f is properly located within under-dis riser containment. Yes I No I N/A <br /> Yes No N/A <br /> Dis nser- 112 _---�--- Orr <br /> Dix Ener--314 -- --- Dis riser- 11/12 <br /> pj,sLxns5i --516 Dispenser- 13114 _ <br /> rDis nser- 7/$ _ Dis nsw - 15/16 1 <br /> PAPERWORK INSPECTION Yes No N/A a e Do <br /> c <br /> 9. Moninxinf System Certification was completed within the past 12 tntinths? 1 -- <br /> 10. Line Leak Detect—were tested certified withinthe past 12 months? <br /> 11. S ill bucket(containment structure testin a+nifileled within the past 12 mortths? <br /> 12. Line pightnecs testin com_ti k[ed within the required time frame? <br /> 13._ 5eamdar co_ntainmetn tests completed within the required it frame? <br /> 14 Enhanced leak Detection com Acted within the nuired time frame? <br /> 15. Other r• uired testis maintenance was co leted within r wired time frame? 11 i t test mTenrnnnre item. rtow.l <br /> Describe-Cestiklaintenanee: <br /> Describe'fest/Maintenance: 11 <br /> FACILITY EMPLOYEE TRAINING _ __ _ Yes o N/A <br /> l6. Have apt facilit employees received the required nn-rh_e:job training within the past year.., t <br /> I7. Have all faci1a em Io ees hired within the aN 30 days received the required on-the-'ob trainin . <br /> Nae: Exylnia any-No-answers in the'Y'omments-section on the following page-'FM)se issues require corrective action from <br /> the US 1 owno+iuycratut 9269!' <br />