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UNDERGROUND STORAGE TANK SYSTEM <br /> DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT <br /> Facility Name: v.JInspection Date: A � <br /> �ilyiCKf7/4Acs <br /> Faciiity,address• Cily <br /> Name of Designated UST Operator Conducting Inspection: w,�,.,,yg'L 'arJ40-' <br /> International Code Council Certification No.: .� 3Expiration Date: <br /> Signature�� Phone: f Bb)�/4 yo 11 ext. <br /> N/A=Not A ''able <br /> hent' h10NITORING PANEL/ALARM HISTORY Yes No N/A <br /> 1. Is(lie nw_nitoring stem veered on and in proper a crating mode? <br /> 2 Is the monitoring system not current) showin�any leak alarms'? <br /> 3 I is the Alarm History Report/log for the previous month available,and has it been reviewed by the <br /> Designated UST Operator? (Attach a copy of the alarm history rzpnrtAog to this inspection nem.) <br /> _ <br /> 4. Has each alarm for the previous ttnmth been resporI to aplimpriately'? <br /> IfS'r sYSTEM INSPECTION _ <br /> 5. Are tank-top containment sumps free of water,debris,and hazardous substance? Ndr. tf the w.rwer u,hem a.a 'W, <br /> to item 6. Simian Where an alarm has mrurred m the paw naNII muet br impri red.if a gwtlif+ed.wnlre trrhnie=hm nut rrrrxmdrd W. aml <br /> nmrrly rrddrcswd,rhe rmt.rr, rJer alarm._Orw'nmrnlMi<in ver+ yin r /t ewer.wnw sluwhl be w"4,_!d N thi.+rr tr. <br /> Yes Na Yes No <br /> Sum Location: Sum Location: <br /> Sum Location. Sum Location: <br /> 6. Arespilt buckets(containment structures) free of water,debris,and hazardous substance'? <br /> Yes No- No NIA <br /> Tank I ID- Tank 41D- <br /> T:ink 2 1 D- _ Tank 5 1D- ❑- <br /> Tank 3 DD- rank fi ID- <br /> 7. Are under-di- ser containment areas free of water.debris,and hazardous substance? _ <br /> Yes No N/A 1'rs No N/A <br /> Pis nser --t/3- -----� Dis nser-9/10 --___ <br /> Dispenser -3/4 Dis nser-- 11//2 I Ll <br /> Dis •nser-SJ6 t __ Di: nser- 13/14 <br /> I Dis riser 7/8 ---- Dis lxnser` 15/16.__—_—�_ <br /> 8. Leak deteo ion is n 1 loo:ated within urttler-dis nser containment. <br /> Y • No N/A Yes No NIA <br /> Dis riser-9/10 <br /> Dis nser-3/4 Dispenser- I 1112 <br /> Dis -nser_5/6 Dispenser- 13/l4 _ _____� <br /> Dis nser-- 7/8 _ Dispenser- 15/16 <br /> _PAPERWORK INSPEC CON Yes No N/A D t Done <br /> l � <br /> 9. Monitoring System Certification was completed within the ast 12 months? <br /> 10. Line Leak DMecton were tested/certified within the pasl 12 months: _ <br /> 11. S ill bucket(containment structurel iesting co leted within the ast 12 months? <br /> 12. Lin_e_tightnesti testin con- rimed within the required ranee frntne' <br /> 13. Secumlar cuntainrrtent test,¢cum toted within the r -aired tithe frame? as �' <br /> l4. Enhanced lzak Detection cum /¢seri wi0lin the t a red time frame! <br /> 15. Other r aired testi maintenance was con Icled within r aired time frame? (LJst tr.ctimaintenance items below.) <br /> (¢scribe Te:sli&laintenance: _ <br /> Describe'Cest/M aintenance: <br /> FACILITY-Eh7PLOYEE TRAINDNG_,___._- __._ Yes No N/A_ <br /> I& THave all facility ein toyees received It required un-rh_e training within the past.year?T <br /> l7. Have all faciiit employees hired within the ast 30 do s received the aired on-the-ob trainin . <br /> Notin e: Explaany"Nd'answers in the`Comments"se tion on the following page.Those issues require arrrective action from <br /> the US-1 ownerhtperaa>[. 9716915 <br />