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ID <br /> ,n <br /> OU 0 20080 <br /> ENVIRONMENTHU LTH <br /> PF'R tm rr/'S'PERI ` ICES' <br /> UNDERGROUND STORAGE TANK SYSTEM <br /> DESIGNATED UST OPERATOR MQNTHLY INSPECTION REPORT <br /> Facility Name: Inspection Date: 2-0 1 <br /> Facility Address: city: <br /> Name of Designated UST Operator <br /> RIC-F_ <br /> International Code Council CWifi.fi..No.-. QC Expiration Date: <br /> Signature: ✓ C(lb-4D2. <br /> A Not Applicable <br /> Item MONITORING PANEL/ALARM HISTORY Yej Na I NIA <br /> 1. Is the monitoring system powered on and in proper 22SE!tan mode? TZ <br /> 2. Is the monitoring system not cuffently showing any leak alarms? TX <br /> 3. Is the Alarm History ReportAog for the previous month available,and has it been reviewed by the <br /> Designated UST Operator? Attach a co ofilie alarm history r2qrqqg to this ins pectionjonn.) <br /> 4. Has each alarm for the previous month been res6nded to MEE21! 'atcly2 <br /> UST SYSTEM INSPECTION <br /> 5. Are tank-top containment sumps free of water,debris,and hazardous substance? Note:If the answer to Item 4 was-Yes,"skip <br /> to Item 6.Sumps where on alarm has occurred in the past month must be inspected if qualified service technician has nor responded to,and <br /> oddrexsgi,the cause ofthe alarm.Documentation vert yinjZ appropriate service should be attached to ihis repo <br /> YC31 No M _Xe! No <br /> Sump Location: >�Pk_ <br /> ;Zt:80 Sump Location: <br /> SumpLocation: Sum Location: <br /> 6. -Are spill buckets(eo!jqLr�m t structures free five of water,d ris,and hazardous substance? <br /> ^ -, <br /> Ye4 No N/AYes No <br /> Tank I ID- b�� <br /> Tank 4 ID 77 <br /> PL <br /> 01 <br /> Tank 2 ID <br /> Tank 31D--- 17> EA <br /> 7. Are under-dispeinser containment-areasffeo of water debris,and hazardous substance? <br /> IIIYes No N/A I Yes No NIA <br /> Dieraser-1/2 <br /> P- DiSR <br /> e2ser <br /> -9/10 <br /> Dispenser-3/4 Dis eraser-I1/12 <br /> Dipenscr-516 Dispense, <br /> -Qa <br /> Bkb�r <br /> Dispenser-7/9 144& <br /> 8. Leak detection is propedy located within tinder-dimetiser containment. <br /> Yes I No N/A Yes No NIA <br /> Di ser-1/2 Di2enser-9110 <br /> Diser-3/4 Dispenser—11/12 <br /> DiEpMn-516 Dispenser-13t-b4 <br /> Dispenser-7/8 <br /> 7A Ione <br /> PJAte Do <br /> PAPERWORK INSPECTION Yes <br /> 9. Monitoring Systern Certification was completed within the past 12 months? <br /> 10. Line Leak Detectors were tested/certified within the past 12 months? <br /> Spill bucket containment structure)t�completed within the past 12 months? <br /> Line ti tress testing com2letod within the required time frame? <br /> Secondary containment tests completed within the required time frame? <br /> 14. Enhanced Leak Detection completed within the required time frame? <br /> 15. Other required testing/mainteriance was completed within required time frame? (Usl les as enan items below. <br /> Describe Test/Maintenance: <br /> Describe Maintenance: I W <br /> FACILITY EMPLOYEE TRAINING Yes No NIA <br /> 116. Have all facility employees received the required on-the-job training within the past year? <br /> rT <br /> NIA <br /> 1 17. Have all facilLty eMloyens hired within the past 30 days received the!Mired on-thetra;nine7 _F <br /> Note: Explain any"No"answers in the"Comments"section on the following page.Those issues require corrective action From <br /> the UST owner/operator. <br /> UN-057-1/2 www.unidocs.org 9/26105 <br /> 0 (4knl tip 5- <br /> V-V� <br /> _T/Vj <br />