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UNDE10'GROUND STORAGE TANK SYSTEM <br /> DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT <br /> F } Nie: Inspection Date: S 0� <br /> s02r47 <br /> Facility Address: 7 ls� �1� �ttay C1Ty' <br /> Name of Designated UST Operator Conducting Inspection: /Ijt(e�� <br /> International Code Council Certification No.: S 2 i fi s^3L ,� Expiration Date: <br /> Signature: Phone: ) (�7p.t�47/ ext. <br /> N/A-Not A icabre <br /> Item MONITORING PANEL/ALARM HISTORY [Yesl No I N/A <br /> 1. Is the monitorin system powered on and in proper operating mode? El <br /> 2. Is the monitoringsystem not currentlyshowinganleak alarms? — <br /> 3. Is the Alarm History Reportllog for the previous month available, and has it been reviewed by the <br /> 1 11 <br /> Designated UST Operator? Attach a co o the alarm historyre ort/lo to this inspection form.) <br /> 3. Has each alarm for the revious month been res og cl to a ro riatel 4 <br /> N <br /> UST SYSTEM INSPECTION <br /> 5. Are tank-top contairunent sumps free of water,debris,and hazardous substance? Note:Ifthe answer to Item 4 W"Yes,"skip <br /> to Item 6. Sumps when an alarm has occurred in the past month must be inspected if a qual fed servtoe technician has not responded to, and <br /> t21D <br /> sszd icauee alarm.Documenmtionvert in a ro r(ate service should be attached to this re (. <br /> Yes No Yes No <br /> ion: Sum Location:ion: Sum Location: Li <br /> 6. ketnt structures free of water debris,and hazardous substance? <br /> Yes No N/A Yes No N/A <br /> Tank 4 ID— <br /> I ank 5 1 D— <br /> Tank 3 ID— Tank 6 ID— <br /> 7. Are under-dispenser containment areas free of water,debris,and hazardous substance? <br /> Yes No N/A YesJ No I N/A <br /> Dispenser—1/2 Dis enser—9/10 <br /> Dispenser-3/4 Dis nser- 11/12 <br /> Dispenser—516 Dispenser— 13/14 <br /> Dispenser—7/8 Dispenser— 15/16 <br /> 8. Leak detection is properly located within under-dis enser containment. <br /> Yes No N/A Yes I No I N/A <br /> Di ser- 1/2 R I D 11 El Dispenser—9/10 <br /> Dispenser—3/4 Dispenser— I I/12 <br /> Dis nser—5/6 Dispenser— 13114 <br /> D' nser-718 Dis enser- 15x16 <br /> EMK <br /> _ PAPERWORK INSPECTION Yesj No N/A Date in <br /> 9. Monitoring System Certification was completed within the past 12 months? 3 11 t I ab <br /> 10. Line Leak Detectors were tested/certified within the past 12 months? I 3 a <br /> 11. Spill bucket containment structuretesting completed within the past 12 months? db <br /> 12. Line tightness testing completed within the required time frame? El R N ab <br /> 13. Secondary containment tests completed within the required time frame? 130 4 <br /> 14. Enhanced Leak Detection completed within the required time frame? S t as <br /> 15. Other required testing/maintenance was completed within required time frame? List test/maintenance items below. <br /> Describe Test/Maintenance: <br /> Describe Test/Maintenance: El <br /> ,,: <br /> FACILITY EMPLOYEE TRAINING Yes No N/A <br /> 16. Have all facilit employees received the required on-the-job training within the past ear? Lf 01 <br /> 17. Have all facili employees hired within the post 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 /> UN457.12 www.unidoes.org 926/05 <br />