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UNDERGROUND STORAGE TANK SYSTEM DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT Facility Name: Ip, L—T.g0 l C jWn Inspection Date: , `2,;:Y` 1 Facility Address: -;7 I N UL.,DO eprq0 ST CityCt(TntJ Name of Designated UST Operator Conducting Inspection: I E N PP� (_ International Code Council Certification No.: t]::)U 3 1 G L► — U C. Expiration Date: 3 Signature: Phone: (5j0)CR9LALj(:gext. LWI N/A-Not Applicable Item MONITORING PANEL/ALARM HISTORY WE] o N/A the monitoringsystem powered on and in proper operating mode? ❑2. Is the monitorin s stem not currentl showin an leak alarms? ❑ 3. Is the Alarm History Report/log for the previous month available,and has it been reviewed by the ❑ ❑ Designated UST Operator? Attach a copy o the alarm histo re ort/lo to this inspection form.) 4. Has each alarm for the previous month been responded to appropriately? ❑ ❑ UST SYSTEM INSPECTION 5. Are tank-top containment sumps free of water,debris,and hazardous substance? Note:q'the answer to Item a Was"res. to Item 6.Sumps where an alarm has occurred in the past month must he inspected(fa qualified service technician hat not responded to,and properly addressed,the cause o the alarm.Documentation ve ri tin•u yro nate service should be attached to this report. Yes I No I I Yes No Sump Location: I E I ❑ I I Sump Location: ❑ Sump Location: I U1 ❑ I F—SumpLocation: I I I ❑ 6. Ares ill buckets containment structures free of water,debris,and hazardous substance? Yes No N/A I Yes.1 No N/A Tank l ID— I LIJ Li ❑ Tank 4 ID— ff ❑ Tank 21D— ❑ Tank 5 ID— 0 ❑ Tank 3 ID— Tank 6 ID— El I ❑ 7. Are under-dispenser containment areas free of water,debris,and hazardous substance? Yes No N/AI Yes No N/A Dispenser— 1/2 LIJ Dispenser—9/10 Dispenser—3/4 Dispenser—11/12 Dispenser—5/6 [� ❑ Dispenser—13/14 LJ El ❑ Dispenser—7/8 ❑ ❑ Dispenser— 15/16 El El 8. Leak detection is properly located within under-dis inser containment. Yes No N/A I Yes No N/A Dispenser—1/2 Q ❑ Dispenser—9/10 Dispenser—3/4 ❑ El I Dispenser—I 1/12 ❑ ❑__ Dis enser-5/6 BL ❑ I Dispenser—13/14 ❑ Dis ser—7/8 ❑ ❑ I Dis enser—15/16 ❑ ❑ PAPERNN ORK INSPECTION Yes I No I N/Al Date Done 9. Monitoring System Certification was completed within the past 12 months? 10 1 ❑ " I I 10. Line Leak Detectors were tested/certified within the past 12 months? [�} Elt t 11. Spill bucket containment structure)testing completed within the past 12 months? ❑ 12. Line tightness testing completed within the required time frame? El I El I El 13. Secondary containment tests completed within the required time frame? ❑ I ❑ 14. Enhanced Leak Detection completed within the required time frame? I Q ❑ d �' 15. Other required testing/maintenance was completed within required time frame? List test/maintenance items below. Describe Test/Maintenance: ❑ ❑ ❑ Describe Test/Maintenance: FACILITY EMPLOYEE TRAINING Yes No N/A 16. Have all facility employees received the required on-the-job training within the past ear? ❑ 17. Have all facility employees hired within the past 30 days received the required on-the-job training.? ❑ 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-057-1/2 www.unidocs.org 9i26/05