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UNDERGROUND STORAGE TANK SYSTEM <br /> DESIGNATED UST OPERATOR MQNTHLY INSPECTION REPORT <br /> Facility Name: <br /> inspection Date: <br /> 7"'y -j- (n CIA <br /> Facility Address: <br /> -Name-o-,J'Dcsignat ST rator Lon uctin9inspection: <br /> Internafio-IC.dv—Council Certification—N..-. Ic'1117 <br /> t ate: ry <br /> Sign <br /> t) 1j1- <br /> Pho ib q02-, <br /> Not APPIkable <br /> Item MONITORING PANEL/ALARM HISTORY Yes No N/A <br /> the n I <br /> 1. Is the o itoringsysterm powered T and in proper operat --M <br /> _Lrtg mode? LJ <br /> 2. Is the m5nitatm not current! showing any leak alarms? <br /> --T- Is the Alam History Reponft for the previous month available,and has it been reviewed by the <br /> — DesigLmtod UST Operator? (Attach a ca y 9f the alarm history nq�rO to this iH�ctionform) <br /> 4. Has each alam for the previous month been riately? <br /> uespondodjo appr(Wn <br /> UST sysnnd INSPFX"ON <br /> 5. Are tank-top eont"w�ientxw�nps-6w-of water,debris,and hazardous substance? Note:ff the answer to Item 4-as 'Ya."skO <br /> to Item 6.Sumps where an alarm has occurred in the past month must be inspected jra qual(fied service technician has not responded to,and <br /> ro ert addrc==scd.the cause of the alarm Documentation riareservice s ou attached to this report. <br /> Yes IYes <br /> SRE!p Location: Sum tion: -1fc] <br /> 0 <br /> 'r <br /> Sum Location: Sum Location: I Ll I Li <br /> 6. Are spill buckets coats' r-O <br /> of water,debris and hazardous substang0l� <br /> Yes No -N/A I Yes jNo <br /> Tank I ID- I El f n I I I Tank 4 ID <br /> Tank Tank <br /> Li <br /> Tank 3 E)- 61D- <br /> -J. <br /> areas 7. Jel�speraser ontainment at M:Water,debris,and hazardous substance? — <br /> Yes 3N--.-FN—1A A AA 7-0 No N/A <br /> Dit�,,=enser- 15��pser—9/10 <br /> i 17 <br /> Disp r- <br /> Dis <br /> Dis p <br /> Tenser- - <br /> Dispenser <br /> Z I <br /> Dis user- I DisPertser- 15/16 2.1 <br /> -1 <br /> E. Leak detection is j!!2Vcriy local within r-dispenser containment. <br /> 9 )No I N4 10 m .-C IYeAl No NIA <br /> Dispmscr:- o <br /> D! eser-9110 <br /> D, <br /> Dis <br /> Di ser-11/12 <br /> "nse <br /> Dis r-1, DisMnscr-13/14 <br /> D <br /> 15/16 zz--I111El <br /> –llllmlll—,�, <br /> PAPERWORK INSPECTION es No IN/A Date Done,/ <br /> 9, - 16nittbring SXAM Certification was cornpfeted within the past 12 months? <br /> 10. Line Leak Detectors were tested/certified within the past 12 months? <br /> El <br /> _Ll.- Spill bucket(conWnrnent structure)tS§1ja completed within the past 12 months? I <br /> 12. Linc ti testi-gScoTpletedffithin the required time frame? -- U I <br /> 13. Secondary cortmim=t tests coEjRleted within the required time frame? U <br /> 14. Enhanced Leak Detection coinJeted <br /> within the required time fiwne? [I <br /> 15. Other requit-od testinWinaintertance was completed within ? nc <br /> Describe Test/Maintenance: time frame �!n aintenanc items below) <br /> Describe Test/Maintenance: <br /> FACILITY FAVLOYEE T NG Yes No N/A <br /> I& Have all facility employees received the required on-t_ho-15-15 training within the pastyear? <br /> 17. <br /> Have all facility employees hired within thease days received the required on-theo-job tra----- <br /> P <br /> Note: Explain any"No"answers in the"C tion on the following page.Those issues require;corrective action from <br /> the UST owner/operator. <br /> UN-057-1/2 <br /> ,n-vyw.ouldocs.org 9/26105 <br />