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UNDERGROUND STORAGE TANK SYSTEM DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT FacilityName: �� t9�.LA/IYl Inspection Date: 1 Facility Address: J - City: Sf Ck Name of Designated UST Operator Conducting Inspection: N t � International Code Council Certification No.: 15,14 31 el 4 U C Expiration Date: Signature: Phone: 90) b ff N/A=\ot Applicable Item MONITORING PANEL/ALARM HISTORY Yes o I N/A 1. Is the monitoring stem powered on and in proper operating mode? 111 ❑ 2. Is the monitoring stem not currently showing any leak alarms? ❑ ❑ 3. Is the Alarm History Report/log for the previous month available,and has it been reviewed by the ❑ ❑ Designated UST Operator9 Attach a copy of the alarm history report/logreportllog to this ins ection orm. 4. Has each alarm for the previous month been responded to appropriately? ❑ I ❑ UST SYSTEM INSPECTION 5. Are tank-top containment sumps free of water,debris,and hazardous substance? Note:If the answer to Item 4 was"Yes,"skip to Item 6.Sumps where an alarm has occurred in the past month must he inspected if a qualified service technician has not responded to,and properly addressed.the cause of the alarm.Documentation verih-ing appropriate service should he attached to this report. Yes No Yes No Su Location (9 ❑ Sum Location: 1 ❑ Sumn Location: Sump Location: 6. Are spill buckets containment structures free of water,debris,and hazardous substance? Yes No N/A Yes No N/A Tank 1 ID— y2C I &I ❑ I Tank 4 ID— Tank 2 ID— ❑ Tank 5 ID— ❑ ❑ Tank 3 ID— the4J I Pr ❑ Tank 6 ID— ❑ ❑ 7. Are under-dispenser containment areas free of water,debris,and hazardous substance? Yes No N/A Yes No N/A Dispenser—112 Dispenser—9/10 ❑ ❑ Dispenser—3/4 Dispenser—11/12 El 1:1 Dispenser—516 D' ❑ ❑ Dis ser—13/14 ❑_ _❑ Dispenser—7/8 ❑ Dispenser—15/16 ❑ 8. Leak detection is properly located within under-dis er containment. Yes I No I N/A I Yes No N/A Dispenser—1/2 a D I Dispenser-9/10 Dispenser—3/4 ❑ Dispenser—11/12 ❑ ❑ Dispenser—5/6 ❑ ❑ Di —13/14 ❑ ❑ Rr Dispenser—7/8 ❑ enser—15/16 ❑ ❑ PAPERWORK INSPECTION Yes No N/A Date Done 9. MonitoringSystem Certification was completed within the past 12 months? ❑ ❑ \h 1 10. Line Leak Detectors were tested/certified within the past 12 months? El q 11. Spill bucket containment structure testingcompleted within the past 12 months? ❑ ❑ �1 12. Line tightness testingcompleted within therequired time frame? ❑ —" 13. Second containment tests completed within therequired time frame? 1 I 1 fo 14. Enhanced Leak Detection completed within the required time frame? ❑ 15. Other required testing/maintenance was completed within required time frame? List testrmaintenance items below.) Describe Test/Maintenance: I ❑ I Ll I ❑ Describe Test/Maintenance: I LJ I Ll I ❑ FACILITY EMPLOYEE TRAINING Yes No N/A 16. Have all facility employees received the required on-the-job training within the past ear? 77EM ❑ 17. 1 Have all facility employees hired within the past 30 days received the required on-the-job ining ? LKn I ❑ Note: Explain any"No"answers in the"Comments"section on the following page.Those issues require corrective action from the UST owner/operator. UN-057-112 www.unidocs.org 9/26/05