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UNDERGROUND STORAGE TANK SYSTEM DESIGNATED LIST OPERATOR MONTHLY INSPECTION REPORT Facility Name: Inspection Date: Facility Address: q „� � ,/� gCity: Name of Designated UST Operator Conducting Inspection: r, �f/L 6N�� International Code Council Certification No.: S 241°vG Expiration Date: It Signature: Phone: &�) y�o-,o 1/ ext. N/A-Not A olicable Item MONITORING PANEL/ALARM HISTORY Ye& No N/A 1. Is the monitoring system powered on and in proper operating mode? — 2. 1 Is the monitoring system not currently showing any,leak alarms? 3. Is the Alarm History Report/log for the previous month available,and has it been reviewed by the Designated UST Operator? Attach a copy of the alarm history reporillog to this ins ecrion orm. 4. Has each alarm for the revious month been res onded to a ro riatel ? UST SYSTEM INSPECTION 5. Are tank-top containment sumps free of water, debris, and hazardous substance? note:If the answer to Item a was"Yes,"skip to Item d. Sumps where an alarm has occurred in the past month must be inspected if a qualified service technician has not responded to, and properly addressed,the cause ofthe alarm.Documentation pert n o nate service should be attached to this report Yes No Yes No Sump Location: _ Sum Location: Sump Location I U I Ej Sump Location: Li Li 6. 1 Are Rill buckets containment structures free of water, debris,and hazardous substance? Yes No N/A Yes No N/A Tank I ID— Tank 4 1 D— Tank 2 ID— _ Tank 5 ID— Tank 3 ID— Tank 6 ID— 7. Are under-dispenser containment areas free of water,debris,and hazardous substance? __ Y No I N/A I Yes No NIA Dispenser— 1/2 Dispenser—9/10 Dispenser— A Dispenser— I I 1/12 Dispenser—5/ Dispenser— 13/14 Dispenser—718 Dispenser— 15/16 8. Leak detection is properly located within under-dispenser containment. Yes I No I NIA I I Yes I No I N/A Dispenser— 1/2 E1.1-DisDenser-9/10 Dis nser-3/4 Dis enser— 11/12 Dispenser—516 Dis nser- 13/14 Dispenser—7/8 Dis e —15/16 PAPERWORK INSPECTION Ye No N/A Date Done 9. Monitorin System Certification was completed within the past 12 months? _ 2 Nrd l0. Line Leak Detectors were tested/certified within the ast 12 months? S afa 11. Spill bucket containment structure?testing completed within the past 12 months? L 12. Line tightness testingcompleted within the required time frame? S11 dq 1-l�condary containment tests completed within the required time frame? 14. Enhanced Leak Detection completed within the required time frame? t 15. 1 Other required testing/maintenance was completed within required time frame? List test/maintenance items below. Describe TestlMaintenance: Describe Test/Maintenance: FACILITY EMPLOYEE TRAINING Yes No N/A 16. Have all facilit employees received the required on-the-job trainingwithin the past year 17. Have all facili employees hired within the past 30 days received the required on-the-'ob training.? Note: Explain any"No"answers in the"Comments'section on the following page.Those issues require corrective action from the UST owner/operator. DN-057-72 www.unidocs.org 926/05