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UNDERGROUND STORAGE TANK SYSTEM DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT Facility Name: 1 JC O nO3 tiw U.L� Inspection Date: ® 31 2.01 Facility Address: 13122 OWOO City: VD Name of Designated UST Operator Conducting Inspection: t Q1 , Ot•_ t International Code Council Certification No.:5')j,-69 4-U c- �� 1 � -iExpiration Date: �- Signature: Phone: N/A= otApP&2ble Item MONITORING PANEL/ALARM HISTORY YesNo N/A 1. Is the monitoringsystem powered on and in proper operating mode? El2. Is the monitoring system 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 Er ❑ ElDesignated USTOperator? Attach a copy of the alarm history report/logreportfiog to this ins ection ortn. 4. Has each alarm for the previous month been responded to a22roeriatel ? ❑ ❑ 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 erl•addressed,the cause n the alarm.Documentation veri &,ing yppro riate service should be attached to this report. Yes No Ycs No Sump Location: TW- lul Sum Location: f GS Sump Location: 0th 1 Lr I III Sump Location: 6. Ares ill buckets containment structures free of water,debris,and hazardous substance? Yes No N/A Yes No N/A Tank 1 ID— ❑ ❑ Tank 4 ID El ❑ Tank 21D— 91 Tank 5 ID— ❑ ❑ [�i' Tank 3 ID— ❑ ❑ Tank 6 ID— 7. Are under-dispenser containment areas free of water,debris,and hazardous substance? Yes,1 No N/A YeF, No N/A Dispenser—1/2 a ❑ Dispenser—9/10 Dispenser—3/4 Dispenser—11/12 Dispenser—5/6 ❑ Dispenser—13/14 0 EF-11 119 Dispenser—7/8 9R, ❑ Dispenser—15/16 ❑ ❑ 8. Leak detection is properly located within der-dispwser containment. Yes No N/AI Yes No I N/A Dispenser—1/2 V ❑ - ispenser-9/10 Dispenser—3/4 M ❑ El I Dis enser-11/12 1q, ❑ I El Dispenser—5/6 Z ,❑ ❑ I Dispenser—13/14 ❑ Dispenser—7/8 ❑ ❑ I Dispenser—15/16 ❑ ❑ PAPERWORK INSPECTION Yes No N/A Date Done 9. Monitoring System Certification was completed within the past 12 months? [2' ❑ Ell� l 10. Line Leak Detectors were tested/certified within the past 12 months? B ❑ ❑ '-I 11. S ill bucket containment structure testingcompleted within the past 12 months? 12. Line tightness testingcompleted within therequired time frame? El Ell 13. Second containment tests completed within therequired time frame? ❑ ❑ 1 1 S� 14. Enhanced Leak Detection completed within the required time frame? ❑ ❑ al V 15. Other required testing/maintenance was completed within required time frame? (List test/maintenance items below. Describe Test/Maintenance: ❑ ❑ ❑ Describe Test/Maintenance: ❑ I ❑ I ❑ FACILITY EMPLOYEE TRAINING Yes No N/A F16. Have all facilityemployees received the required on-the-job trainingwithin the past ear? ❑ El17. Have all facility employees hired within the past 30 days received the required on-the-job training.? ❑ ❑ Note: Explain any"No"answer;in the"Comments"section on the following page.Those issues require corrective action from the UST owner/operator. UN-057-1/2 www.unidoes.org 9/26/05