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UNDERGROUND STORAGE TANK SYSTEM <br /> DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT <br /> Facility Name: qp <br /> W Inspection Dale: / C/ <br /> Facility Address: qb 55C s y' <br /> Name of Designated UST Operator Conducting Inspection: Robert Bamhart <br /> Intemationa ouncil CertificationNo.: 5252540-UC Expiration Date: 12/23/2011 <br /> signatur _ Phone: (209)604-9336 ext. <br /> N/A^Not AP able <br /> Item MONITORING PANEL/ALARM HISTORY Yes No N/A <br /> 1. Is the nionitoriyu,s stem nnwered on and in ro r o eratin model <br /> 2. Is the monitoring system notcurrently showing any leak alarms? <br /> 3. Is the Alarm History Report/log for the previous month available,and has it been reviewed by the <br /> Desi ated UST erator? Attach a co o the alarm histo re ort1lo to this ins ection orm. <br /> 4. Has each alarm for the nmvious month been res onded to a ro riatel ? ❑ <br /> � F <br /> UST SYSTEM INSPECTION <br /> 5. Are tank-top containment sumps free of water,debris,and hazardous substance? Nue:/f the answer to Item 4 was "Yes,"skip <br /> to Item 6. Sumps where an alarm has occurred in the pose month must be inspected iia qualfied service technician has not responded to, and <br /> property addressed the cause of the alarm.Documentation vert in a ro r/ate service should be attached to this report. <br /> Yes go <br /> Yes No <br /> Sum Location: �lil`i�iluill� Sum Location: <br /> Sum Location: " H'^ Sum Location: <br /> LJU a <br /> 6. Ares ill buckets containment structures free of water debris and hazardous substance? <br /> Yes No N/A Xes No N/A <br /> Tank I ID— Tank 4 ID— <br /> Tank 21D— Tank 5 ID— <br /> Tank 3 1D— Tank 6 ID— <br /> 7. Are under-dis eraser containment areas free of water,debris,and hazardous substance? <br /> Y7 1 No N/A 17I 1 Yes 1No N/A <br /> Dis nser— 1/2 ❑ ❑ I Dis ser-9/10 <br /> Dis enser-3/4 1 bel I I I i I I I Dis eraser— 11/12 <br /> Dis nser-5/6 I IN I ❑ ❑ Dispenser— 13/14 <br /> Dis enser-7/8 1 rr Dis nser- 15/16 <br /> 8. Leak detection is to erl located within under-dis enser containment. <br /> Yes No NIAmpispenser <br /> . 17 S Yes No N/A <br /> Dis enser— 1/2 iser-9/10 <br /> Di enser-3/4 — 11/12 Ug I Li I <br /> Dis nser-5/6 Dis nser- 13/14 <br /> Dis enser-7/8 ❑ Dts ser- 15/16 <br /> IQ IM11 <br /> „t PAPERWORK IN Yes No <br /> N/A Date Done <br /> 9. MonitoringSystem Certification was completed within the past 12 months? L:' 1'0 <br /> 10, Line Leak Detectors were tested/certitiied within the past 12 months? 12' -0 <br /> IL Spill bucket containment structure testi2f,co m feted within the 2ast 12 months? <br /> 12. Line tightness testing completed within the required time frame? <br /> 13_ Secondary containment tests com leted within there uired time frame? I Lf—to_0 <br /> 14. Enhanced Leak Detection com Ieted within the required time frame? <br /> 15. Other required testis maintenance as completed within required time frame? Lis,test/maintenance items below. <br /> Describe Test/Maintenance: H I <br /> HI <br /> h/ 7 <br /> ., Test/Maintenance: <br /> EMPLOYEE <br /> Describe Tes <br /> FACILITY E TRAINING Xes <br /> No I N/A <br /> s received the required on-te-ob training within the t year?MH7a <br /> 17. Have all facilityemployees hired within the past 30 days received the reureon <br /> . <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 /> urv-0s7-In <br /> www.unidocs.otg 9/26/05 <br />