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%W0 <br /> UNDERGROUND STORAGE TANK SYSTEM <br /> DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT <br /> Facility Name: inspection Date, q ? ob <br /> 1kw72Y ���c'f7PG n Q3r <br /> Facility Address: 1 3' �r C16*Wz cite: <br /> Name of Designated 11Sr Operator Qxulucting Inspection: A/L7ir✓r1�G Q�(,40f <br /> Expiration <br /> Phone: (��9} 1//0 t/Fi/i ext. <br /> --�\ WA c not A .•thio <br /> ;iRINC PANEL/ALARM UISTORY YesNo N/A <br /> .•.'. in proper cgxxatmg mode! <br /> .kowing any leak alarms <br /> previous month available,and has A been reviewed by the <br /> U ,..r t.ri els<•aai r> tlttrt:•l { ,o yo thenfannhistory,reporylogtothisinspectionforret.) <br /> 4. Has each alarm for the previcius mnih t><•en res ntded to a rt iatet ? <br /> ja 7-T <br /> _ UST SYSTEM INSPECTION <br /> 5. Arc tank-top contairuncut sumps free of water,debris,and hazardtws subslancc'? Nar:lfdxw,.,.era,h nr 4",o "Ye,.' .A4, <br /> i m rhr pili iNnnh nw?i be in,prrird i/a qualified xrvirr tr.hnirran ha,w.x r.rpnwtrd m, nal <br /> y nanlunao rcr,'vin u n, riots.wrvuz dawhl tr wturhrd ru rhi,rr ,rr. <br /> __ ' Yes No Yes No <br /> muni L,,Katioo Sum Location: <br /> Sump Lttcatios _ Sum Location; <br /> 6. Are s ill buekets(containment stnn:t=s)free of wate_r_debris,and hazardous substance? 5'es jNoINA <br /> Yes No N/A —_ <br /> 'rank i ID- Tank 4 ID- ff <br /> Tank - - Tank 5 ID- <br /> 1 Tank 3 ID Tank 6 ID <br /> At, :a,icr- , r ra :,+}i4it i,ustt.t .-.free of water.debris,and hazardous substance'! <br /> _ <br /> _ _ -- Yes No N/A Yes No N/A_ <br /> �t "sti �i <br /> Dispenser—9110 — <br /> Dis nser 11/12 <br /> l!z:.•,.,:>,., Dis •reser— {3114 __ <br /> -- <br /> Z �drounder-dis nsercontaimtunt. yes NO NA <br /> Yes No N/A _ _ <br /> Dis nser-9/10 <br /> y <br /> Dispenser- 11112 <br /> Dispenser- 13/[4 <br /> 7� -�— --- — Dispenser— 15/(6 <br /> tDRK INSPE('1'lON Y No N/ADate��Done <br /> v,-- ojnpleted within the ast 12 months? b-111o.>.L <br /> 10. Line Leak Detectors were test-ed/certified within the 12 months? hjt <br /> y,, t tr< testis co Iered within the past 12 months? <br /> r an t ut;:t ,�Pt_�'r4 within the uireg red time frame? <br /> ,,A within the aired time frame? <br /> f r m w erw, cont,. ithin the r° uired time frame? <br /> _i,,completed within required tune frame? (last tesUrnointenance derri.t below.) <br /> lhxribe Test/Maintenance: <br /> Descr;,.ibe Test/Malntenance: <br /> _ FACILITY EMPLOYEETRAINING_ Y No N/A <br /> 16. Have all facility employees received the required nn-thelob lrainin within the past ear'? . <br /> i7. Have ail facility employees hired within the st 40 da s received the aired on-the-'ob trainin . <br /> Note: Explain any. "No"answers in the"Comments"section on the following page.Those issues require corrective action from <br />