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Farpu �f�►1Y`�T��"1) hl�l�%12011 Namr ti )1,1, NI) N.1.O1t ar'iht Ito 1'O A(. TAMC MON-1•III,V �; OK FP VS I'F M ` address..._ 12 INSPF. ,F," N R " --_ `renatrci b _ 091[ c [ o alar t undlrcli ` - RignanrR^_-' -k1c uncrll'"itit, �Rlnspc�boo_,._- '- Myon No.: r_`-.___.__�__ Fs_9 ----_S a I_1� Fixpiration Da[e , Is thr n)onitOrin MON Phony. (`5?,j 35 fi i ZE Xt v urMe ` � Is the rnonit systen) 0wered t rORING PANk:L/ tits=Vnr.a p/A Is the ql.l oriel` systrm 1 _in not on and in rtr e�o�1=AR HISTORY Y� N I�rsiCnstcd USTIfZto^ ReporNlog fi)r it sbowin.an Irak art -mode? r 4. j Ufa's e —O orator•? he previous ms? each alarm iii le drtac•h a , p o th<tnont ,available,an v )rcvi - alarm d has it been reviewed by the nus month been re h+uarl rePor/ga to thio ins ectiarr arm. s)onded to- r Are tank c a ? +er Ire•m r; P ontainmcm swn UST SYSTF,M INS ro natel ? 'ZIPS),.her ps Free or water, de I PECTION rn.x•rh'addretis'ed, a an alarm has tx'cnrred bris, and hazar „Y-eS."skip the, o//he a/or in l!/e Pns/month nolo// dons substance? Note, If answer In/tem 4 was In. and m' Lir+cume•nlot, veil •tn a my aed foq�a//fed service technician luu nor resptr+ ed S U mLocationa 'ra n'tate service should he coached to this re r!. : Yes No Sum Location: Yes No 6. I Are s ill bucketsSun) Location: (containment structures) free of water,debtum Location:h Tank 1 1D- Yes No N/A hazardous substance? No N/A h ,. Yes Tank 2 ID_ , Tank 4 ID- Tank 5 ID-- Are under-dis enser Tank 6 ID- substance? containment areas free of water, debris, and hazardous subst Drs enser- 1/2 Yes No N/A NIA Dis enser-- 3/4 Yes No Dis enser-9/1p Dispenser 5/6 Dis enser- 11/12 Dis enser— 7/g Dis enser— 13/14 Leak detection is properly located within under-dis enser coDntainment.is 15/16 Dis enser— 1/2 Yes No N/A Yes No N/A Dis enser— 3/4 Dis enser—9/l0 Dis enser-5/6 Dis enser - 11/12 Dispenser— 7/8 Dis enser- 13/14 Dis enser-- 15/16 PAPERWORK INSPECTION Yes No N/A I Date Done AIullufurmg S stem Certification was completed within the past 12 months? Line Leak Detectors were tested/certilied within the ast 12 months? 3 20 Z Spill bucket (containment structure) testing completed within the past 12 months? N El I El 1 W .� 5!1 o f•L ,me IiQhtni testing completed within the required time frame' Z i y ec:and containment tests completed leted within the re uired time frame? El El •nhanced Leak Detection com leted within the required time frame? nher required testing/maintenance was completed within required time frame? List test/inaintenance items below.) Describe 7'eWMaintenance: Ides_ cry`7•estlMaintenance: � __ - FACILITY EMPLOYEE TRAINING Yes No NIA. ve aU ity employees received the required on-tile job training within the Past Yi ve all aii em Jo ees hired within the past 30 days received the required on-the-job training.? On=�"No"answer in the "Continents" section on the following page. Those issues require corrective itRiN ST"Mwlopta Or. is