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UNDERGROUND STORAGE TANK SYSTEM <br /> DESIGNATED INT OPERATOR MQNTHLY INSPECTION REPORT <br /> Facility Name: A <br /> Inspection Date: <br /> FWL( G <br /> Facility Address- City: <br /> Nan- of Designated UST Operator Conducting Inspection: <br /> lxitcrnatipv.�Code Council Certification No. Expiration Date: <br /> SignaturikPhone: C(t �2WA <br /> Not Applicable <br /> Item MONITORING PANEL I AIARM HISTORY Yes No N/A <br /> 1. Is the monitoring system L>awered on and in proper omode? tin 1 <br /> 2. Is the monitoring DLVEm not currently showing any leak alarms? 4�51 <br /> tZ114# <br /> 3. Is the Alum M"Report/log for the previous month available,and has it been reviewed by the <br /> RS��tcd UST Operator? Lilach a Lo&!?�Ihe alarm history reporter to this fnWAionLorm.j <br /> — <br /> 4- Has each alarm for the prev.ious .-month been responded to appropriate[Y. <br /> VST SYSTEM INSPECTION5. Are tank-top_containment stumps free of water,debris,and hazardous Substance? 849tC:orthe 4nSWCr 10 11CM 4 Was"Yes."snip <br /> 10 11d*T 6.Swrnps wAwjV an alarm has OC"rred in the pas:month must be inspected 6ra qwftfied service technician has not responded to,and <br /> +n r! addressed,the cause o the alarm, e.10fion riate service should be aunched to this reporc <br /> Y 0 Yes <br /> Sump <br /> Location: ��� Stem <br /> Location: <br /> Location: <br /> U 111 <br /> 6, Are spill buckets(�,o ctures lee of water,debris,and hazardous subs <br /> —_ .4 Yes No N/A I Yes No NIA <br /> Tank I ID- Tank 4 ID- <br /> Ta Tank 5 <br /> 3 U)- <br /> M <br /> diLmuscr containment water, <br /> i_n <br /> 7. Are und7cr--dis mmen,Aweas If 1,1 ter,debris,and hazardous substance? <br /> -No NIA No N/A <br /> Di eraser-1/2 El El I Dispenser-9/10 <br /> IN T��r- <br /> 31j El El 0 <br /> Di eraser-516 -z,6 13/14 <br /> Dispenser-7/8 15116 <br /> 9. Leak detection is propel ly located within un er-dispenscr containment, <br /> 1?Ves CN(l I N/A Yes_j)No I NIA <br /> 4 <br /> Dis:p5=r-112 <br /> Irl Di ser--9/10 <br /> Di -3/4 !2.-7 11/12 <br /> D Ispen <br /> Di -WO 'V 10, 1AA Disliense - 13/14 <br /> dl� D=-15/16 <br /> PAPERWORK INSPECTION Yes No NIA I Date Done <br /> 9. Monitaritt S stem Gerritcation was cam feted within the act 12 months? <br /> Ji EL A I <br /> 10. Line <br /> Il. � H <br /> ­ ---d <br /> 12. Line ti tress testis cam feted withnt the re uired time frame? <br /> 13. Seco containment tests com feted within the required tune frame? <br /> K Enhanced <br /> El <br /> _15. Other required testier maintenance was completed within required time fume? inienance items below) <br /> Describe TcWMaintename: <br /> DescribeTest/Maintenance: <br /> FACILITY EMPLOYEE TRAP41NO Yes No NIA <br /> 16. Have all fkciliemployees received the Leguired on-Ute <br /> _j2!kA-Xt'ninF <br /> within the past year? <br /> 17. Have all facility employees hired within the past 30 dagy&rfeeeived the zequited on-th!,-job aainina.? U Li <br /> Note: Explain any"No"answers in the"Comments"s * on the following page.nose issues require corrective action from <br /> the UST owner/operator. <br /> UN-057-if2 <br /> 9/26105 <br />