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UNDEITGROUND STORAGE TANK SYSTEM <br /> DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT <br /> Facility Name: A Inspection Date: ! r� <br /> Facility Address:/7kLeCity: 3�e.ter, <br /> Name of Designated UST Operator Conducting inspection: <br /> International Code Council Certification No.: S-Ly K34, F/G Expiration Date: }l t✓ <br /> Signature: Phone: <br /> N(A-moiApplicable <br /> RI. Is <br /> MONITORING PANEL/ALARM HISTORY Yes No N/A <br /> the monitorin s stem owered on and in ro er o ratin mode? <br /> s the monitorin s stem not current) showin anleak alarms? <br /> s the Alarm History Report/log for the previous month available, and has it been reviewed by the <br /> Desi ted UST O erator? Attacha co o the alarm histor re ort/lo to this!ns ection orm.Has each alarm for the revious month been responded to appropriatel ? <br /> UST SYSTEM INSPECTION <br /> 5. Are tank-top containment sumps free of water,debris,and hazardous substance? Note:IJthe answer to Item 4 was "Yes,"skip <br /> to Gem 6. Sumps where an alarm has occurred in the past month must be inspected if a qualified service technician has not responded to, and <br /> ro rl addressed,the cause o the alarm.Documentation veri in appropriate service should be attached to this report. <br /> Yes No Yes No <br /> Sum Location: Sum Location: <br /> Sum Location: Sum Location: <br /> 6. Are s ill buckets containment structures free of water,debris,and hazardous substance? <br /> Yes No N/A Yes No N/A <br /> jArD— Tank 4 ID— <br /> D— 0111 LLJj <br /> Tank 5 ID— <br /> D— Tank 6 ID- <br /> 7. r-dis enser containment areas free of water,debris,and hazardous substance? <br /> Yes No N/A Yes No N/A <br /> r— 1/2 Dis enser—9/10 <br /> r-3/4 Dis enser- 11/12 <br /> r-5/6 Dis enser— 13/14 <br /> r-7/8 Dis enser— 15/16 <br /> ection is ro erl located within under-dis nsercontainment. <br /> YeNo N/A Yes No I NIA <br /> r- 1/2 Dis enser-9/10er-3/4 Dis enser— 11/12er-5/6 Dis enser- 13/14 Li I Li <br /> Dispenser—7/8 Dis enser— 15116Li I Li I El <br /> PAPERWORK INSPECTION Yes No N/A Dalte Done <br /> 9. M mitorin System Certification was completed within the past 12 months? t t ab <br /> 10. Line Leak Detectors were tested/certified within the past 12 months? 1 t <br /> 11. Spill bucket containment structuretesting completed within the past 12 months? i at <br /> 12. Line ti mess testing completed within the required time frame? <br /> 13. Secondary containment tests com leted within the re uired time frame? l,X <br /> 14. Enhanced Leak Detection completed within the required time frame? <br /> 15. Other re uired testin maintenance was completed within required time frame. List tesUmainrenance items below. <br /> Describe Tesi Maintenance: <br /> Describe Test/Maintenance: <br /> FACILITY EMPLOYEE TRAINING Yes o N/A <br /> 16. Have all facility employees received the required on-the-job training within the past ear? <br /> 17. Have all facili em 10 ees hired within the past 30 days received the required on-the-'ob trainin .? al 0 <br /> Note: Explain any"No"answers in the"Comments"section on the following page. Those issues require corrective ACtion ff0M <br /> the UST owner/operator. <br /> UN-057-1!1 www.unidoc®.org 9/26/05 <br />