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s <br /> UNDERGROUND STORAGE TANK SYSTEM <br /> DESIGNATED UST OPERATOR MQNTH LY INSPECTION REPORT <br /> Facility Name: , Inspection Date: < <br /> FacilityAddress: <br /> .- <br /> _ AddJ-> City; ` r <br /> Name of Designated UST Operator Conducting Inspection: ', v obp <br /> International Code Council Certification No.: 6�5e)67y .. VC Expiration Date`:, <br /> Signature: • phone: Cub,q0z 3x2.3cl <br /> Y NIA w No:Appbcable <br /> Itew MONITORING PANEL/ALARM HISTORY Y No N/A <br /> 1. is the monitoring stem powered on and in proper operating mode? 1171 <br /> 2. Is the monitoring tem not currently sho!LAAO any leak alarms? <br /> 3. Is the Alarm history ReportAog for the previous month available,and has it been reviewed by the rm# <br /> Designated USTOperator? Attach a e9a of the alarm history repoqjto this inspection orm. <br /> 4. Has each alarm for the revious month been responded toro 'atel ? <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,"sAip <br /> to Item 6.Sumps where an alarm has occurred in the past month must be Inspected 4r qualified service technteian has not responded to,and <br /> to rl addressed,the cause o the alarm.Documentation seri 'n ro state service should be attached to this report. <br /> Yes No Yes - <br /> Stun Location: Sum Location: <br /> Su Location: - Sump location: <br /> 6. Ares ill buckets containm ctures free of water,debris,and hazardous substance? <br /> Yes No N/A _ Yes No NIA <br /> Tank 1 ID- 0 1 Li Tank 4 ID- _ <br /> Tank - Tank S <br /> 3 ID-- -_— T 6 ID-- _ <br /> 7. Are under--dispenser containment areas free of water deb s and hazardous substance? <br /> 'L77 VA Yes I No NIA Yes No NIA <br /> Di enscr- rL C,, Dispenser- _. <br /> Dispenser-1419. si'o_LL__._ . <br /> IJi croser- <br /> Disperaser-154-4- <br /> Dispenser <br /> Di nser- 4Ul Di ser- 1 ' <br /> 8. Leak detection is pEqperly located within ummu -dispenser containment. <br /> Yes No I LDij <br /> Yes No N/A <br /> Di serVKDi r- se -- <br /> ser- 2 rtADis er- fit{ ser- $• <br /> TTH <br /> PAPERWORK INSPECTION Yes No NtA Date Done <br /> 9. Monitoring System Certification was completed within the past 12 months? _ <br /> 10. Line Leak Detectors were tested/certified within the past 12 months? <br /> l 1. Sill bucket containment structure)testing completed within the past 12 months? <br /> 12. Line tightness testing completed within the required time frame? <br /> 13. Secondary containment tests completed within the required time frame? <br /> 14. Enhanced I eak�Detection com leted within the uined time frame? <br /> 15. Other re mai <br /> Bred testis ntenance was completed within uired tim c? Est lesthnaintenance nems below. <br /> Describe Test/Maintenance: <br /> Describe Test/Maintenance: <br /> FACILITY OYES TRAINING Yes No N/A <br /> 16. Have atl facility employees receive aired on-the-job training within the pastyear? <br /> 17. Have all facility em la ee within the past 30 days received the required on-the`'ob trainin <br /> Note: Explain any'No"AaWeirs in the"Comments"section on the following page.Those issues require corrective action from <br /> the UST a operator. <br /> UN-057-12 www.onldocs.org 9126105 <br />