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Designated Underzround Storage Tank (T ST) Operator <br />Monthliv suai fnsoeetiori Cneeiclzst <br />Facility Name: "y( y;L Date: 1 l l Z 3 <br />Facility_ Address:i'T� <br />l <br />Ctry ^4►�1v e c1.; ;Zia Code: <br />Deshmaled UST Clperawr Conducting the luspection: <br />International C9de Cou 1 C46fication 4: . 1-f-0 �' j L ! Expiration Dale.- 1'2_ Z 6- <br />Signature- <br />Sisgnature- ! Phone-_( j'0 p ') • 6 0_ Q y +.t 3 i <br />- Y = Yes _ No. �iA =Not appdecable <br />i Item I %dnN TnVjNC D A NUT. i A I A 0 Na =Qrr"Q V v <br />Vote: .-fav answer of `NY should be explained in the comment sermon on the following page. and will require <br />follow-up action. <br />!'ye 1 or"_ September 1004 <br />I MoniEoring system is Dowered on and in proper operating mode. <br />19 System is not currently s6owing any alarms or warnin__ us, <br />; <br />3 ! Alarm history ret"V109 for the previous month is available. and bas been Tevicwed by the <br />Qes� UST Operator. (4nach a copy of the alarm history reporrIlog to this. brm if availabie.} <br />i <br />4 + Each alarm for the previous month has been responded to ar promately. <br />5 I Sensors located in tank -top conUbment sumps have not alarmed in the past month. <br />3a i - List all tank -top sumps inhere alarms occurred in the past month: a t` ( .�.� (� � � /� ✓ t-a� <br />Vale Sumps where an alarm iiat occi;7rd m the past month rant be Inspected w less a yualifreu mrvrce teclvt wn responde-d to, _,Md <br />Properly addmm.e.the cause of die aiwm. _Affair documentaam verOmrS appropriate service to ihrs report. <br />i%s'unw is rrywred teeorri nesrtiu in item b, below. <br />UST SYSTEM INSPECTION - <br />6 Tank -top containment sumps are free of water. debris. and hazardous subs== Sensors are located properly. a <br />i -vote.- Vintal rnspeciion of Simms is only red in mimm where at alarm hm occrmed in the pant month for which there is no mrwce recrnrt <br />a <br />n <br />Y Y <br />; Sump Location: 1 i ;;." :'; ✓-* Sump Location: <br />! Stanp Location: Sump Location: a <br />Sump Location: j 1 Sumv Lacation: - <br />i mill conmimuent structures are free of water. debris, and hazardous substance. <br />l <br />Y N NAI _Y i�Y �I NA <br />Tank l — Cornetts: 7 i Tank 3— Coments: <br />Tank 2 — Contents: Ct I✓ Tank 4 — Contents- 1 3 <br />3 ;Umder-dispenser containment areas are fire of water, debris, and hazardous substance. Sensors are located properly. <br />Y AK Y Y r NA 1 <br />Dispenser 1! 3 1 I Dispenser 11 i0 I <br />Dispenser 3! -i Dispenser <br />Dispenser 5,,'6 1 Dispenser 13 •' 14 j ! <br />Disyenser 78 ( (Dispenser 15 .' 16 s <br />_ - <br />a I <br />9 Monit system crstiftca tion has been co feted within past 12 mombs. <br />!0 1 Secondary commmment tests have been ampleted within the required ntne*ame. <br />! 1 ` Soil] conminmeut structure (bucket) testis was completed within the 'vear. 1 l G y <br />12 Tank Ughtness testing was completed wtthan required ttmefiww. <br />13 t Line tigfimess testing was compieted with required timeframe- I j <br />14 '. Cher reouired tesuWrnaintenance was completed within required timeframe. 'list iest/maintenance items below. ^� <br />! 7"tW1,tainte rance: ; <br />1=Waintenance: 71---L�; <br />I Test/Maintenance: 1 j <br />Vote: .-fav answer of `NY should be explained in the comment sermon on the following page. and will require <br />follow-up action. <br />!'ye 1 or"_ September 1004 <br />