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UNDE'AGROUND STORAGE TATIrK SYSTEM <br /> DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT <br /> Facility Name: /csa_L Inspection Date: I 2 (/ <br /> Facility Address: 7 .$ ✓r� bAl 111� City: JxdC1,?ai.) 1 <br /> Name of Designated UST Operator Conducting Inspection: /J"kd f— <br /> International Code Council Certification No.: Expiration Date: N <br /> Signature: Phone: ) Ll/o vlext. <br /> N/A=Not Applicable <br /> Item MONITORING PANEL/ALARM HISTORY YesL No I N/A <br /> 1. Is the monitoring system powered on and in proper operating mode? <br /> LIs the monitoringsystem not current) showinganleak 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 O erator? Attach a co o the alarm histor re ort/lo to this ins ection orm.Has each alarm for the revious month beenres onded to aro riatel ? <br /> UST SYSTEM INSPECTION <br /> 5. Are tank-top containment sumps free of water, debris,and hazardous substance? Note:lithe 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 qualified service technician has not responded to, and <br /> prpffrly addressed the muse o the alarm.Documentation ver i in Fu <br /> uve service should be attached to this report. <br /> Yes No Yes fl <br /> Stun Location: m Location: <br /> Sump Location: = Sump Location: U I i <br /> 6. Ares ill buckets containment structures)free of water,debris, and hazardous substance? <br /> Yes No N/A I I Yes I No N/A <br /> Tank I ID— 2 1 El I Tank 4 ID— <br /> Tank 2 ID— Tank 5 ID W Li <br /> — <br /> Tank 3 ID— I ha I Lj I Lj I Tank 6 ID I Li Li Li <br /> — <br /> 7. Are under-dispenser containment areas free of water,debris and hazardous substance? <br /> Yes I No I N/A i No N/A <br /> Dispenser— 1/2 Dis enser—9/10 <br /> Dispenser—3/4 !Dispenser— I 1/12 <br /> Dispenser—5/6 Dis enser— 13/14 <br /> Dispenser—7/8 Dis enser— I S/16 <br /> 8. 1 Leak detection is properly located within under dis enser containment. _ <br /> Yeti I No I N/A I Yes No I N/A <br /> Dispenser— l/2Dis enser—9/10 <br /> Dispenser—3/4 Dis enser- 11!12 <br /> Dis nser—5/6Li Li Dis enser— 13/14 <br /> Dispenser—7/8 Dispenser— 15/16 1:11 El I Ej <br /> PAPERWORK INSPECTION Yes.1 No N/A Date Done <br /> 9. Monitoring System Certification was completed within the past 12 months? t z <br /> 10. Line Leak Detectors were tested/certified within the past 12 months? F1 I LJ :91,,( a8 <br /> 11. Spill bucket containment structure testing completed within the past 12 months? El 111 1 3 I-LI as, <br /> 12. Line tightness testing completed within the required time frame? Id"'.13. Secondarycontainment tests completed within the required time frame? g y <br /> 14. Enhanced Leak Detection completed within the required time frame? s` <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: <br /> a•,:,. <br /> FACILITY EMPLOYEE TRAINING Mo <br /> 16. 1 Have all facility employees received the required on-the-job training within the past year? <br /> 17. Have all facility employees hired within the past 30 days received the required on-the-'otrainin .? <br /> tvowr ExPtd:n e.,y••rvo•ar,�.,-ers :n rn�••co.nroenu••scction on the following page. Those issues require corrective action from <br /> the UST owner/operator. <br /> UN-057.IR www.unidoes.org 913M <br />