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UNDERGROUND STORAGE TAN-vt SYSTEM DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT Inspection Date: Facility Name: /j�;t Facility Address: . /, C�(ve. ✓✓`/ City: J%ud7J� Name of Designated UST Operator Conducting Inspection: ylrr 5,�Ad L _ Expiration Date: l l n +[b International Code Council Certification No.: S24 ��6^-k- Phone: �� eim,,voll ext. Signature: N/A=nota liaeble Item MONITORING PANEL/ALARM HISTORY Yes No NIA L Is the monitoring system powered on and in—)toper o crating mode? 2. Is the monitorin s stem not current showin an leak alarms? 3. Is the Alarm History Report/log for the previous month available,and has it been reviewed by the Desi ated UST Operator? Attach a co o the alarm history revort/log to this ins ection form. 4. Has each alarm for the revious month been res onded to a ro natel ? UST SYSTEM INSPECTION 5. Are tank-top containment sumps free of water, debris,and hazardous substance? Nae:If he answer to item 4 was "Yes."sA;F to Item 6. Skimps where an alarm has occurred in the past month must be inspected if a qual jed service technician has not responded to, end r rt addressed,the cause o the alarm.Documentation verW service should be anached to ihls re rG Yes NO Yes No Sum Location: Location: Sum Location: Location: 6. Are s ill b 111 1 Li uckets containment structures free of water,debris,and hazardous substance? Ye I Yes No N/A Tank 1 ID— Tank 4 ID— 10 1 Li Tank 2 ID— Tank 5 1 D-- Tank 3 ID— Tank 6 ID— 7. Are under-dispenser containment areas free of water, debris,and hazardous substance? Yes No N/A I Yes No I NIA Dispenser— 1/2 Dispenser—9/I O Ej Dispenser—3/4 Dis enser— l i/12 t Dispenser—5/6 Dis enser— 13/14 Dispenser—7/8 1 L I U j Dispenser— 15/16 8. Leak detection is properly located within under-dispenser containment. Yes I No I N/A I Yes No NIA Dispenser— 1/2 1 LJ I L I Dis enser—9/10 Dis nser-3/4 Dispenser- 11/1 2 _IH Li Li Dis nser—5/6 Dis enser— 13/14 Dis enser-7/8 Dis enser- 15/16 �M&111L PAPERWORK INSPECTION Yes.I No I N/A Date Done 9. Monitoring System Certification was completed within the past 12 months? LJ I Lj 3 I 1 L ck5 10. Line Leak Detectors were tested/certified within the past 12 months'? �112 11. Spill bucket containment structuretesting completed within the past 12 months? 14a.'A 12. Line tightness testing completed within the required time frame? 1 1 13. Secondary containment tests completed within the required time frame? s U. 14, Enhanced Leak Detection completed within the required time frame? d 15. other required testing/maintenance was completed within required time frame. List rest/maintenance items below. Describe Test/Maintenance: _ Describe Test/Maintenance: FACILITY EMPLOYEE TRAINING Yes I No 1.N/A 16. Have all facility employees received the required on-the-job training within the past ear? 17. 1 Have all facility employees hired within the past 30 days received the required on-the-job training.? Note: Explain any"No"answers in the"Comments"section on the following page. Those issues require corrective action from the UST owner/operator. UN-057.1/2 www.unidues.org 9/26MS a.