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UNDERGROUND STORAGE TANK. SYSTEM <br /> DESIGNATED IJST OPERATOR MQNTRLY INSPECTION REPORT <br /> Facility Namea.: J Inspection Date: 6A6-, 2 b <br /> Facility Address: .Z City: <br /> Name of Designated UST Operator Conducting Inspection: 4 1CF 'L,�� <br /> International Code Council Certification No,: �5 �67{t,r vC Expiration Date: <br /> Signature: CJ L/ Phone: G;14b q02. <br /> NIA Not APPLIcable <br /> Item V MONITORING PANEL/ALARM HISTORY Yes No N/A <br /> 1. is the monitoring stem powemd on and in proper operating mode? - <br /> 2. Is the monitoring m not currently 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 /> Designated USTOperator? Attach a nVy o the alarm history repoyAM to this inspectionform.) 012 Q <br /> 4. Has each alarm for the revious month been res ded to!Mropriatcly9 <br /> UST SYSTEM INSPECTION <br /> 5. Are tank-top containment sumps free of water,debris,and harardons substance? Note:If-the answer to tier"4 was"Yes,"s+hp <br /> to Irem 6.Sumps where an alarm has occurred In the past month must be inspected#a qualified service iechntcian has not responded to,and <br /> ry r addressed,the cause o the alarm.t)ocumerttarion veri in oQriate service should be attached to this report. <br /> Yes No Yes No <br /> SumpLocation: SjnR Location: tA- _ <br /> _ S unip Location: I I I = Sump Location: Ar <br /> 6. Ares ill buckets(containment structures)free of water,debris and hazardous substance? <br /> - -^~ Yes No NIA Yes No NIA <br /> Tank 11D- Tank 4 ID- - El I <br /> "Tank 2 ID- El El 0 Tank 5 ID- <br /> _ Tank 3 ID- Tank 6 ID- <br /> 7. Are under-dispenser containment are f water,debris and hazardous substance? <br /> es o NIA es o NIA <br /> Dispenser Dispenser v11 <br /> Da r- - Dis enser- <br /> Di 1 Di ertser- <br /> Dis ser- 26 gy, Dispenser- 1 4 <br /> 8. Leak detection is pro rly located wi r-dispenser containment. <br /> es No I N/A 2fJ i-0-14 <br /> Di ser- Di enser-94.9o- 7j VK <br /> Di ser --- -- -- Di nser- <br /> E -nser- Dispenser- <br /> Diser to Ammiiiiiii EaDis scr <br /> PAPERWORK INSPECTION Yes No NIA Date Don <br /> 9. Monitoring System Certification was completed within the past 12 months_? <br /> 14. Line Leak Detectors were tested/certified within the past 12 months? <br /> 11. Spill bucket containment structure testin com lctcd within the ast 12 months? <br /> 12. Line tightness testing completed within the required time frame? a J7 <br /> 13. Secon containment tests completcd within the required time frame?_�. <br /> 14. Enhanced Leak Detection completed within the required time frame? _ <br /> 15. Other required testing/maintenance was com I-ted within aired time frame? t test/maintenance items below. <br /> Describe Test/Maintenance: _ <br /> Describe Test/Maintenance: <br /> FACILITY EMPLOYEE T NG Xes No N/A <br /> 16. Have all facili employees received the required on-the ' trainin within the past .ear? <br /> 17. Have all facilityem to ees hired within the past 3 a s received the required on-the 'ob trainin <br /> Note: Explain any"No"answers in the"Com7:wvvw.on1docs.orZ <br /> tion on the following page.Those issues require corrective action from <br /> the UST owner/operator_ <br /> UN-057-t/2 986M5 <br />