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W/Oel 200714-6 881 <br />Designated Underground Storage Tank (UST) <br />Operator Monthly Document Inspection Checklist <br />Additional corrective acti: <br />ons taken while performing this inspection <br />REv: s.o <br />Item <br />PAPERWORK INSPECTION <br />YComvliant <br />I INA <br />1 <br />Owner Statements of Designated UST Operator Form Present Reference UNIDOC UN -062 <br />✓ <br />2 <br />Monitoring system certification paper work on site. <br />✓ <br />3 <br />Secondary containment test results on site. <br />✓ <br />4 <br />Spill <br />containment structure bucket test results on site. <br />✓ <br />5 <br />Tank tightness test results on site. <br />✓ <br />6 <br />Line tightness test results on site. <br />✓ <br />7 <br />Enhanced <br />Leak <br />Detection test results on site. <br />✓ <br />8 <br />Certification of Financial <br />Responsibility on site. Expiration Date: <br />04/22/21 <br />9 <br />Facility Permitting Authorized <br />Date: <br />01/31/20 <br />10 <br />UST Permitting Authorized <br />Date: <br />01/31/20 <br />11 <br />Monitoring Plan <br />Authorized <br />Date: <br />01/31/20 <br />12 <br />Response Plan <br />Authorized <br />Date: <br />01/31/20 <br />13 <br />Hazardous Materials Business Plan -years Expiration <br />Date: <br />01/31/23 <br />14 <br />Hazardous <br />Materials Annual Inventor (1 -year) Expiration <br />Date: <br />01/31/21 <br />15 <br />Certified <br />Unified <br />Program Agencies <br />CUPA Permit Expiration <br />Date: <br />01/08/20 <br />16 <br />Air <br />Permit - Permit to Operate PTO Expiration <br />Date: <br />08/31/23 <br />17 <br />Other: Date: <br />18 <br />Other: Date: <br />19 <br />Other: Date: <br />DESIGNATED FACILITY EMPLOYEE (DFE) / CLASS "C" OPERATOR TRAINING <br />Y <br />N <br />20 <br />Training Form Present and Current <br />✓ <br />DFE(s) / Class "C" Operator(s) <br />Date Trained <br />a. Jonathan Pakele <br />09/01/19 <br />b. Scott Kicenski <br />09/01/19 <br />C6 <br />do <br />e. <br />f. <br />90 <br />h. <br />MISCELLANEOUS INSPECTION ITEMS <br />21 <br />TEST OVERFILL ALARM <br />Pass <br />Fail <br />NA <br />Test audible and visual functionality for no less than four seconds. <br />22 <br />ELECTRONIC MONITORING CERTIFICATION DECAL DATE <br />04/21/20 <br />23 <br />MONITOR PAPER <br />Percentage of printer paper in the monitoring panel? %: <br />90 <br />Number of additional rolls of printer paper remaining on site? <br />1 <br />24 <br />EMERGENCY GENERATOR UNBURIED FUEL PIPING VISUAL INSPECTION <br />Y <br />N <br />NA <br />Unburied fuel piping visual inspection on the generator run log is accurate and up to date? <br />Additional corrective acti: <br />ons taken while performing this inspection <br />REv: s.o <br />