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UNDERGROUND STORAGE TANK SYSTEM <br /> DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT <br /> Facility Name:�s /• ' Inspection Date: <br /> Facility Address:/0-� ` t CrTy' C OBJ C 2Q <br /> Name of esignated UST Operator Conducting Inspection: �v SOnJ <br /> ]nt'mat' nal C de Council Certification No.:ccfaa �3,(�� Expiration Date:,?,_.,2 <br /> Signa Phone:S �"-� t. <br /> N/A=Not Applicable <br /> Item MONITORING PANEL/,ALARM HISTORY YeslNo N/A <br /> 1. Is the monitoring s stem powered on and in proper o ¢rutin mode? L32. Is the monitorin system not currently showing an leak alarms? ❑ <br /> 3. Is the Alarm History Report/log for the previous month available,and has it been reviewed by the 0 ❑ ❑ <br /> Desi ted UST Operator? Attach a coy of the alarm history report/logreportllog to this ins ection orm. <br /> 4. 1 Has each alarm for the previous month been responded to appropriateW. ❑ ❑ <br /> UST SYSTEM INSPECTION <br /> 5. Are tank top containment sumps free of water,debris,and hazardous substance? Note:If 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 /> properlyprqperly addressed the cause of the alarm.Documentation ver ro nate service should be attached to this report. <br /> Yes No YeAD <br /> Sum Location: ❑ Sum Location: ❑Sum Location: ❑ Sum Location: 103 <br /> 6. Are spill buckets(containment structures)free of water debris,and hazardous substance? <br /> • Yes No N/AI Yes No I N/A <br /> Tank 1 ID— ❑ I ❑ I Tank 4 ID— ❑ ❑ 1 ❑ <br /> Tank 2 ID— 211 ❑ I ❑ I Tank 5 ID— ❑ ❑ ❑ <br /> Tank 3 ID— ❑ ❑ Tank 6 ID— El El <br /> 7. Are under-dispenser containment areas free of water,debris,and hazardous substance? <br /> Yesj No I N/A Yes No I N/A <br /> Dispenser—1/2 0, ❑ Dispenser-9/10 ❑ ❑ ❑ <br /> Di enser—3/4 ❑ ❑ <br /> Dispenser—11/12 ❑ ❑ El <br /> Dispenser—5/6 ❑ 1 ❑ Dis enser—13/14 ❑ ❑ ❑ <br /> Dispenser—7/8 ❑ ❑ I Dispenser—15/16 ❑ ❑ ❑ <br /> S. Leak detection is properly located within under-dispenser containment. <br /> Yesj No I N/A Yes No N/A <br /> Dispenser—1/2 0 W❑ Dispenser-9/10 *EE ❑Dis enser—3/4 ❑ Dis enser—11/12 ❑Dis enser—5/6 D' enser—13/14 ❑ <br /> Dispenser—7/8 ❑ Dispenser—15/16 ❑ ❑ ❑ <br /> PAPERWORK INSPECTION Yes No I N/A Date Done <br /> 9. Monitoring System Certification was completed within the past 12 months? ❑ ❑ I ❑ <br /> 10. Line Leak Detectors were tested/certified within the past 12 months? ❑ ❑ I ❑ <br /> 11. Spill bucket(containment structure)testing completed within the past 12 months? ❑ ❑ 1 ❑ <br /> 12. Line tightness testing completed within the required time frame? ❑ ❑ ❑ <br /> 13. Secondary containment tests completed within the required time frame? El ❑ ❑ <br /> 14. Enhanced Leak Detection completed within the required time frame? ❑ ❑ I ❑ <br /> 15. Other required testin aintenance was completed within required time frame? List test/maintenance items below.) <br /> Describe Test/Maintenance: I ❑ ❑ ❑ <br /> Describe Test/Maintenance: ❑ ❑ <br /> FACILITY EMPLOYEE TRAINING Yesj No I N/A <br /> 16. Have all facility employees received the required on-the-job tr*ft within the past ear? ❑ <br /> 17. Have all facili em to ees hired within the past 30 da s received the r =ob train <br /> aired on-thein .? ❑ <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-057-112 www.unidocs.org 9/26/05 <br />