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Designated Underground Storage Tank (UST) Operator <br />Monrhiv a isuai Inspection Chec:iiist <br />Facilitv Name: N#)1V7- iDate: <br />Facility Address: i 3ll y0 -5e M e -7-e- <br />City: Zip Code: <br />Designated UST Operator Conducting the Inspection: <br />'nternarionai C CQyncil Certification M: S'Z o 4 R u e- —! Ex�iration Date:/ 2 i Zi�-! d 6 <br />Signature: i Pbone: t; t,o n } 3 <br />Y = Yes. N = No. NA= Not Anulicable <br />{item j MONITORING PANEL / ALARM HISTORY' _- - � Y NA <br />1 4lonitorins system is powered on and in nroner operating mode. I <br />Note: Any answer of `°N" should be explained in the comment eetion on the following page. and will require <br />follow-up action. <br />Page i of <br />September =004 <br />Monitoring system is not currently silo any alarms or warnings. <br />Alum history report/log for the previous month is available, and has been reviewed by the <br />Designated UST Operator. !Attach a c of the alarm history repqrv7og report/7oto this orm if'available-1 <br />d <br />Each alarm for the sous month has been responded to appropriately. <br />Sensors located in tank -top containment sumps have not alarmed in the past month. <br />s <br />i - List all tank -top sumps where alarms occurrent in the past monih: _ g <br />i <br />Vote: Sumps where an alarm has occtvred in the past momh must he inspected zmless a qualified service techma= responded to, and <br />,properly addressed the cause of the alarm. Attach documentation -ivnfymg appropr7aw service to this report { <br />— 1 f sump inspection is required record results w item 6. below. 1 <br />UST SYSTEM INSPECTION <br />b <br />— <br />Tank -top containment sumps are free of water. debris, and hazardous substance. Sensors are located properly. <br />.Note: visual inspection of sumps is only required, in su s where an alarm inns occurred in rhe past month for which there is no service record <br />Y <br />Sump Location. ! r <br />S Location: <br />1 Su»m Location: ° <br />Sump Location: f <br />Sump Location: <br />Sump Location: - <br />7 ! Spill containment structures are free of water, debris, and <br />hazardous substance. <br />Y N;NAI <br />1Y N NAl <br />i T atilt 1 -Contents: 0 _ eSe L i L000eiI <br />Tank 3- Contents: I i <br />! Tank 2 - Contents: tlj > t I <br />Tank 4 - Contents: if I I i <br />3 i Under -dispenser containment areas are free of water, debris, and hazardous substance. Sensors are located o erl _ <br />' <br />Y L N NA I Y. V NA <br />Dispenser 1/ Z ! Dispenser 4110 <br />Dispenser 314 { Dispenser II / 12 <br />Dispenser 3 / 6 Dispenser 13/14 I <br />Dispenser 7/ S Dispenser 15 ;' 16 <br />PAPERWORK INSPECTION Y i N NA DATE DONE <br />9 <br />Monitormg system certiiicanon has been completed within put 12 months. ! <br />10 1 Secondary containment tests have been completed within the requurd tunefiame. i <br />11 <br />Spilt containment structure (bucket) testing was completed within the past year_ <br />12 <br />Tank Ughtness testing was compieted within required timeframe. <br />13 <br />Line tightness testing was completed within timeframe. ! <br />14 <br />Other required testing/maintenance was completed within required timeframe. Hist test/mainienance items below.) <br />?'esdti4airrtenanee: ; <br />TestlMaintenanee.-i <br />TestlMaintenance: <br />FACILITY EMPLOYEE TRAINING Y , N NA , <br />15 1 <br />Ali faciiiry emplovees have received the required on-the-job training within the past year. I <br />t ie ! All facility emnlovees aired within the past 30 days have received the required on-the-job training. i <br />Note: Any answer of `°N" should be explained in the comment eetion on the following page. and will require <br />follow-up action. <br />Page i of <br />September =004 <br />