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UNDERGROVND STORAGE DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT Facility Name: f-� , , f F, MONITORING PA14EL/ ALARM HISTORY Inspection Date: 1. 1s the monitoring system p2wered on and in proM operating mode? Facility Address: j ,City: , < . f J Name of Designated UST Operator Conducting Ins ection: Evangeline Barroso-Traylor international Code Council Certification No.: 8200889 -UC 4. Expiration Date: 3/30/2017 UST SYSTEM INSPECTION , Signature: , , . t , �Y,. , _�_.. � � Phone: (909) 455-.2276 ext. Are tank -top containment sumps free of water, debris, and hazardous substance? Vote. /(the answer to Item 4 xas ")es."skip to Item 6. trumps where an alarm has occurred in the past month must he inspected i(a qualrfted serrice technician has not responded to, and ro terh• addressed, the cause of rhe alarun,DDocumentation veriffing appropriate service should he attached to this igxwt. Yes 0 1 Item MONITORING PA14EL/ ALARM HISTORY Yes No I N/A 1. 1s the monitoring system p2wered on and in proM operating mode? 2. Is the monitoring s stem not currently showing any leak alarms? El El 3. Is the Alarm History Report/log for the previous month available, and has it been reviewed by the Desi ated UST erator? (Attach a copy of the alarm history re ort/lo /O I/11S li1SCtlOfl Or7TJ.� 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? Vote. /(the answer to Item 4 xas ")es."skip to Item 6. trumps where an alarm has occurred in the past month must he inspected i(a qualrfted serrice technician has not responded to, and ro terh• addressed, the cause of rhe alarun,DDocumentation veriffing appropriate service should he attached to this igxwt. Yes 0 1 Yes Sum Location s 4-=.-- ❑ « ;? Sum Location: Sum Location: Sum Location: Ila El 6. Ares ill buckets (containment structures) free of water, debris, and hazardous substance. Yes No N/A I Yes I No N/A Tank 1 ID -` Tank 4 ID - El Tank 2 ID - -"> Tank 5 ID - Tank 3 ID -"i Tank 6 ID - 7. Are under -dispenser containment areas free of water, debris, and hazardous substance? Yes I Na I N/AIn Dis enser - 1/2 U310 Dispenser -9/10 Dispenser - 3/4 Dispenser- 11/12 ri EF Dispenser - 5/6 Di s enser -13/14 Dispenser - 7/8 Dispenser -15/ 16 8. Leak detection is pLoperly located within und r -dispenser containment. �Yesj No I NIA Yes No I N/A Dispenser -1 /2 Dispenser - 9/10 El I Ell Dispenser - 3/4 it Dispenser -11 / 12 Dis nser - 5/6 13 Dispenser - 13/14 « Dispenser - 7/8 Dispenser - 15/16 „ ... __. PAPERWORK INSPECTION Yes No N/Al Date Done 9. Monitoring System Certification was completed within the past 12 months? 10. Line Leak Detectors were tested/certified within the past 12 months?- / 11. Spill bucket containment structure testingcompleted within the ast nths? t t 12. Line tightness testing completed within the required time frame? 13. Secondary containment tests cow feted within the required time frame? 14. Enhanced Leak Detection completed within therequired time frame? F1 I F1 I F11- 5_'. Other required testing/maintenance was completed within required time frame? (List tesilmaintenance items below.) Describe Test/Maintenance: Lj 10 1 F1 Describe Test/Maintenance: FACILITY EMPLOYEE TRAINING Yes No N/A 16. Have all facilityemployees received the required on-the-job trainingwithin the past ear? 17. Have all facility em loyees hired within the past 30 days received the required on -the job training ? uvaic: GXlnarn any ivv answcr-s in me %_omments section on me tonowing page, t nose issues require corrective action trom the UST owner/operator. L'N457 -112 ee�4w.unidacs.org 9126/05