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C <br />11- _r' Underground Storage Operator <br />Monthly• • <br />Facility Name: PS- <br />Date: �— <br />Facility Address: ( '3 2�- K), <br />Monitoring system is powered on and in proper operating mode. <br />Ci <br />Zi Code: OtS 2_p <br />Desi nated UST Operator Conducting the Inspection: c <br />cn <br />International Code Council Certification #: <br />Expiration Date: IQ / 2- / OG <br />Signature: <br />Phone: 5-,? c) - ZZ cam <br />Y = Yes, N = No, NA = Not Applicable <br />Item MONITORING PANEL / ALARM HISTORY Y N NA <br />I <br />Monitoring system is powered on and in proper operating mode. <br />2 <br />Monitoring system is not currently showing any alarms or warnings. <br />3 <br />Alarm history report/log for the previous month is available, and has been reviewed by the <br />Designated UST Operator. (Attach a copy of the alarm history report/lo to this form if available. <br />4 <br />Each alarm for the previous month has been responded to appropriately. <br />5 <br />Sensors located in tank -top containment sumps have not alarmed in the past month. <br />5a <br />- List all tank -top sumps <br />re where alarms occurred in the past month: � -g_ c vt I a <br />Note: Sumps where an alarm has occurred in the past month must be inspected unless a qualified service technician responded to, and <br />properly addressed, the cause of the alarm. Attach documentation verifying appropriate service to this report. <br />ffsump inspection is required, record results in item 6, below. <br />UST SYSTEM INSPECTION <br />6 <br />Tank -top containment sumps are free of water, debris, and hazardous substance. Sensors are located properly. <br />Note: Visual inspection of sumps is only required in sum s where an alarm has occurred in the past month.for which there is no service record. <br />Y N <br />Y N <br />Sum Location: `$ Kt <br />Sum Location: <br />Sump Location: <br />Sump Location: <br />Sump Location: <br />Sum Location: <br />7 <br />Spill containment structures are free of water, debris, and <br />hazardous substance. <br />Y N I NA <br />Y N NA <br />Tank 1 - Contents: U <br />Tank 3 - Contents: <br />Tank 2 - Contents: <br />Tank 4 - Contents: <br />S <br />Under -dispenser containment areas are free of water, debris, and hazardous substance. Sensors are located properly. <br />Y N NA Y I N NA <br />Dispenser 1 / 2 Dispenser 9 / 10 <br />Dis enser 3 / 4 Dispense 11 / 12 <br />Dispenser S / 6 Dispenser 13 / 14 <br />Dispenser 7 / 8 Dispenser 15 / 16 <br />PAPERWORK INSPECTION Y N NA DATE DONE <br />9 Monitoring system certification has been completed within past 12 months. <br />10 Secondary containment tests have been com leted within the required timeframe. '? -Z� <br />11 Spill containment structure (bucket) testing was completed within the past year. <br />12 Tank tightness testing was com leted within required timeframe. <br />13 Line tightness testing was completed within required timeframe. <br />14 Other required testing/maintenance was completed within required timeframe. (List test/maintenance items below) <br />Test/Maintenance: <br />Test/Maintenance: <br />Test/Maintenance: <br />FACILITY EMPLOYEE TRAINING Y N NA <br />15 All facilityemployees have received the required on-the-job trainingwithin the past year. <br />16 All facility employees hired within the past 30 days have received the required on-the-job training. <br />Note: Any answer of "N" should be explained in the comment section on the following page, and will require <br />follow-up action. <br />Page 1 of 2 November 2004 <br />