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UNDERGROUND STORAGE TANK SYSTEM <br /> DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT <br /> Facility Name: Gr Inspection Date: <br /> Facility Address: City: Fid✓ <br /> Name of Designated UST Operator Conducting Inspection: ,14£.r- l�7 � <br /> International Code Council Certification No.: 'S'2gS�E ,�� Expiration Date: It <br /> Signature: J Phone: t / /(ext. <br /> N/A-NDIADDlicabit <br /> Item MONITORING PANEL/ALARM HISTORY Yesl No I N/A <br /> 1. Is the monitoring system powered on and in properr operating mode? Ell El I El 1 <br /> 2. Is the monitoring sysim 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 /> Desi ated UST emtor? Attach a copy o the alarm history reportllojz to this inspectionform.) <br /> 4. Has each alarm for the previous month been res onded to gppriatel'? <br /> w <br /> UST SYSTEM INSPECTION <br /> 5. Are tank-top containment sumps free of water, debris, and hazardous substance? Note:Ifthe answer to Item 4 was 'Yes,"skip <br /> to Item 6. Sumps where an alarm has occurred in the past month must be inspected if a qual fed service technician has not responded to, and <br /> mvmrlv addmsm the cause of the alarm.Dccumentatimimrltnit a ro riate service should be attached to this report, <br /> Yes No YesI <br /> Stun Location: Sum Location: Ulu <br /> Sum Location: Sum Location: <br /> 6. Ares ill buckets containment structures free of water,debris,and hazardous substance? <br /> Yes No N/A Yes <br /> Tank 1 ID— Tank 4 ID— El I <br /> Tank 2 ID— Tank 5 ID— <br /> Tank 31D— Tank 6 ID— <br /> T Are under-dispenser containment areas free of water,debris and hazardous substance? <br /> Yes I No I N/A I es o N/A <br /> Dispenser—1/2 Dispenser—9/10 <br /> Dispenser—3/4 1 Dispenser— 11/12 <br /> Dispenser—5/6 Dis nser— 13/14 <br /> Dispenser—7/8 Dispenser— 15/16 <br /> 8. Leak detection is properly located within under-dis enser containment. <br /> Yes I No I N/A I Yes J No j N/A <br /> Dispenser— 1/2 j Lj I Dispenser-9/10 <br /> Dispenser—3/4 Dispenser— 11/12 E51 El I El I <br /> Dispenser--5/6 Lj L Dispenser— 13/14 <br /> Dispenser—7/8Dis nser— 15/16 <br /> FRMIN .,, t'v 4 •,'m;. r., .W <br /> _ PAPERWORK INSPECTION Yes No I N/A Date Done <br /> 9. 1 Monitoring System Certification was completed within the past 12 months? a& <br /> 10. Line Leak Detectors were tested/certified within the past 12 months? a ats <br /> IL Spill bucket containment structuretesting completed within the past 12 months? i tlb <br /> 12. Line tightness testing completed within therequired time frame? i 109 <br /> 13. Secondary containment tests completed within the required time frame? Us <br /> 14. Enhanced Leak Detection completed within the required time frame? z5 t txe <br /> 15. Other reqyired testing/maintenance was cont leted within required time frame? List test/maintenance items below. <br /> Describe TesNMaintenance: <br /> Describe Test/Maintenance: 10 1 <br /> FACILITY EMPLOYEE TRAINING Yes No N/A <br /> 16. 1 Have all facility employees received the required on-the-job training within the past ear? <br /> 17. 1 Have all facility employees hired within the past 30 days received therequired on-the 'ob trainin <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.unidomorq 9/26105 <br />