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UNDERGROUND STORAGE TANK SYSTEM <br /> DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT <br /> Facility Name: / , Inspection Date: <br /> Facility Address: Vis Q�'I CChO�C�0 ty: W�.11.e,11 <br /> Name of Designated UST Operator Conducting Inspection: v q 1 � (2c A�_/t'Vt���� , <br /> International Code Council Certification No.: �U 3( q ^VL ,/C� Expiration Date:3(216 I - <br /> Signature: Phone: (90 6R " 446k}- <br /> N/A=Not A plicable <br /> Item MONITORING PANEL/ALARM HISTORY Yes No N/A <br /> 1. Is the monitoringsystem powered on and in proper operating mode? ❑ <br /> 2. Is the monitoringsystem not current) showinganleak alarms? EJ I--]3. Is the Alarm History Report/log for the previous month available,and has it been reviewed by the E] E]Designated UST Operator? Attach a copy o the alarm histol),re ort/lo to this ins ection orm. <br /> 4. llas each alarm for the previous month been res ondcd to a ro riatclv? ❑ <br /> UST SYSTEM INSPECTION <br /> 5. Are tank-top containment sumps free of water,debris,and hazardous substance? Note:#the answer to Item 4 was "Yes,"skip <br /> to Item 6.Sumps where an alarm has occurred in the past month must be inspected if a qualified service technician has not responded to,and <br /> properly addressed,the cause o the alarm.Documentation vert li"hwapproDriate service should be attached to this report. <br /> Yes No I I Ye No <br /> Sump Location: Sump Location: ❑ <br /> Sump Location: Cj I FS­UMPLocation: <br /> 6. Ares ill buckets containment structures free of water,debris,and hazardous substance? <br /> Ye5. No N/A I Yes No N/A <br /> Tank 1 ID- Tank 41D El <br /> - <br /> Tank 2 ID- ❑ ❑ I Tank 5 ID- ❑ ❑ [vY <br /> Tank 3 ID- ❑ I Lj I Tank 6 ID- ❑ ❑ <br /> 7. Are under-dispenser containment areas free of water,debris,and hazardous substance? <br /> Yes I No I N/AI Yes No N/A <br /> Dispenser- 1/2 0 ❑ I Dispenser-9/10 ❑ ❑ <br /> Dispenser-3/4 W I Dispenser-I 1/12 IT <br /> Dispenser-5/6 LZ ❑ I R I Dispenser-13/14 ❑ ❑ <br /> Dispenser-7/8 ❑ 1 El I Dispenser-15/16 ❑ ❑ <br /> 8. Leak detection is properly located within under-dispenser containment. <br /> Yes I No N/A I Yes No N/A <br /> Dispenser-1/2 ff I ❑ El I Dispenser-9/10 ❑ <br /> Dispenser-3/4 ❑ Dispenser-I 1/12 ❑ ❑ <br /> Dispenser-5/6 Dispenser-13/14 <br /> Dispenser-7/8 ❑ Dispenser-15/16 ❑ ❑ <br /> PAPERWORK INSPECTION Yes No N/A Date Done <br /> 9. Monitoring System Certification was completed within the past 12 months? ❑ ❑ lr.I l 6 <br /> 10. Line Leak Detectors were tested/certified within the past 12 months? N <br /> 11. Spill bucket containment structure testing completed within the past 12 rnonths? ❑ ❑ �► <br /> 12. Line tightness testing completed within the required time frame? ❑ [� t <br /> 13. Secondary containment tests completed within the required time frame? `1f <br /> 14. Enhanced Leak Detection completed within the required time frame? ❑ <br /> 15. Other required testing/maintenance was completed within required time frame? (Gist test/maintenance items below.) <br /> Describe Test/Maintenance: ❑ 0101 <br /> Describe Test/Maintenance: ❑ 10 <br /> FACILITY EMPLOYEE TRAINING Yes No N/A <br /> 16. Have all facility employees received the required on-the-job training within the past ear? ❑ ❑ <br /> II <br /> 17. Have all facility employees hired within the past 30 days received the required on-the-job training.? LEM ❑ <br /> -11 <br /> Note: Explain any"No"answers in the"Comments"section on the following page.Those issues require corrective action from <br /> the UST owner/operator. <br /> UN-057-1/2 www.unidocs.org 9/26/05 <br />