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UNDERGROUND STORAGE TANK SYSTEM <br /> DESIGNATED UST OPERATOR MQNTHLY I-NSPECTION REPORT <br /> F--aci—lity N— <br /> a—m�! e: <br /> !- - ' <br /> Inspection Date* <br /> Facility Ad . E-� City- <br /> CA7e 0f Designated UST Operator Conducting Inspection. <br /> International Code Council Certification No.: Expiration Date- --0 rU <br /> Si <br /> NIA-Not A lsksbic <br /> Item MONT-170RING PANEL/ALARM HISTORY No N/A <br /> 1, Is the monitoring sy5MRTW—M-40n and in proper operating mode? -M-TT <br /> 2. Is the monitoring - <br /> -- 2-9 sy��em-not currently showing any leak alarms? <br /> Is the Alarm History Report/log for the previous month available,and has it been reviewed by the <br /> Desi ted LIST the alarm h!�� to this��Ctte,![�Orm vf <br /> 4- Has each alarm forthelxm <br /> E::ous month been responded to appropriately? <br /> UST SYSTEM INSPECTION <br /> —K Are—tank-top sumps containment — <br /> .sumps of water,debris,and hazardous substance? Note..ifthe answer to Item 4 was stip <br /> to hem 6 Sumps where an alarm Aas occurred in the parr month n1wl be inspected ffa qualified service technician has not responded to,and <br /> the cause ofthe alarm.Documentation veri in riate senishouldbe attached to this report. <br /> Y No Yel No <br /> SurnP Location: Sump Location <br /> SME Location: W .......... q-rrnn Location:on <br /> 0. 1 Are sp!U buckets{containment structures)free of water,debris <br /> ,.and hazardous substance? <br /> Yc No N/A <br /> Tankk I Tank 4 ID <br /> T 2 ID- <br /> tank --—------- . ..... Tank 6' <br /> un, <br /> T under er-Aispcnscr containment areas fre <br /> water.debris,and hazardous substance? <br /> cri=er- o N11t.A <br /> Di <br /> Di <br /> Di eraser Dis curer-I <br /> Dig user— <br /> 8. Leak detection is properly located widtidtmder-dispemercontainment. <br /> o I N/A <br /> No I N/A. <br /> Di user- Diser- <br /> 94* <br /> !�Ttz <br /> Dig - <br /> _ <br /> 1 P 1 P 1 -penser <br /> Di r- Dis?enscr <br /> Dig er- pe-ser-W+(r 117 !5, R1 El 1 11 <br /> PAPERWORK INSPECnON yis No N/A Date Done <br /> �0;0, <br /> _Monitoring was completed within the past 12 months? <br /> Line Leak Detectors were te�dlcerti�fied within the past 12 months? <br /> — --3 _6(0 <br /> _��buc�et containment stnicture)testing completed within the p �12inor�tlrs? <br /> 12. Lille tid1—tn=testjqS completed within ihe required time frame? <br /> 11 Secondary containtnellt tests completed <br /> E2Lnklctcd within the required time frame? <br /> . Enhanced Leak Detection completed within the jr:�Nired time frame? <br /> V-0 <br /> 15. Other lestin./mintenance was completed within Ltgaired time frame? I tes-lhnai ance ilei=below.) <br /> 0 1 EJ lkq <br /> — <br /> Describe TcsV <br /> FWfaintcnance: -kO <br /> JUJUj <br /> FACILITY EMPLOYEE TRAINING Yes No N/A <br /> 16. Rave a1R facility employees received the required on-the job training within the past y,eaL? <br /> 17. Have all facrlrt employces hired within the vast 30 days received the required on-the-job training.. <br /> Note: Explain any"No"answers in the"Comm <br /> n on the following pagenose issues reqi <br /> the UST ownerloperator, "Comments"sectio . tire corrective action from <br /> UN-057-112 vrWW.Vn1docs.org 9(26105 <br />