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UNDERGROUND STORAGE TANK. SYSTEM <br /> DESIGNATED ITST OPERATOR MQNTHLYINJSPECTION REPORT <br /> facility Name: Inspection Date: <br /> Facility Address: } f! City: <br /> L� <br /> Name of Designated UST Operator Conducting Inspection; • �International Code Council Certification No.: /�'� �07 _ uC Expiration Date. � •zo, rU <br /> Si ✓ -- Phone: Ct qV;2_- <br /> NIA••Not A plicabIt <br /> Itettt MONITORING PANEL/ALARM HISTORY Yes No I NIA <br /> I. Is the monitoring system powered on and in proper operating mode? <br /> 2. Is the monitoring system not currcnt]X showing any leak alarms? <br /> 3. is the Alarm History Report/log for the previous month available,and has it been reviewed by the <br /> Desisted UST Operator? (Attach a copy of the alarm history teporl log to this Inspection orm. <br /> 4.-_ Has eacb alarm for the now rvvious month been responded to 'atel ? <br /> US'C'SYSTEM INSPE,CnON <br /> 5. Are tank-top contain=11t sumps five of water,debris,and hazardous substance? More:Jfthe answer to was-Yes."skip <br /> 10 Item 6.Sumtu when an alarm has occurred in the past monsh must be inspected' a <br /> F pec If qualified service tee! as not responded to,and <br /> ro rufdrrssee�the caata o the alarm_Docttrarentation veli riate eervfee should be a o this rt. _ <br /> Yes No Yes No <br /> Sum Location: _�.�_ ocation: _____ <br /> Swirp,Location: Surn Location: <br /> 6. Ares ill buckets containment structures of water debris,and hazardous substance? <br /> Yes No N/A �^ Yes jNo <br /> Tank 1 ID— Tank 4 ID— '+ <br /> Tank 2 M— Tank 5 ID_ <br /> 1 a 3 IDTank 6 ID— <br /> 7 re undo_r-dispenser containment area water debris and hazardous substance? <br /> No N/A 2 n1 a No N/A <br /> Di enser—1/2I�jr� Di ser-9/IO <br /> �ispextser-3� _ Di enser-11/12 Z'' _ <br /> Di --5/6 . enser--13/14 •z <br /> Dispenser—7/8 �p U .1 Dis ser—I S/l6 <br /> 8. Leak detection is properly located wi -dispenser containment. <br /> es No <br /> NIA No N/A <br /> Di —1/2 _Vr 0 1 0 Dispenser—9/10 <br /> Di —3/4 *y i Dispenser—11/12 <br /> Di er--5/6 M Dispenser-13/14 Zf <br /> Dis er—7/8 y Dis ser—15/16 2•(/ <br /> _ <br /> PAPERWORK INSPECTION Yes I No N/A DatsamfL <br /> 9. Mq!_!Wring System Certification was completed within the past t2 months? El <br /> 10. -Lisle Leak Detectors were tested/certified within the past 12 months? <br /> _1L 1. S ill bucket contaiammt structure testin completed within the 2ast 12 months? <br /> 12. Line ti ttness resort com Icted within the required time frame? <br /> 13. Secondary containment tests completed within the required time frame? <br /> I4. Enhanced Leak Detection coTpleted within the required time frame? <br /> d5. Other mgdurd lestinpfrnaintenance was completed within required time frame? est/maintenance items below. <br /> --- - <br /> Describe Test/Maintcnance: <br /> Describe Test/Maiatenance: <br /> FACILITY EMPLOYEE TRAIN? Yes I No I N/A <br /> 16. 1 Have all facili em to ees received the required on-the-job Uallijng within the past ear? <br /> 1,7..,_l Have all faclli em to ees hired within the East 30 da eived the required on-the—job trainm' / <br /> Note: Explain any"No"answers in the"Comments"sec' on the following page.'Chose issues require corrective action from <br /> the UST owner/operator, <br /> UN457-112 www,untdocs.org 9/26105 <br /> c <br />