Laserfiche WebLink
UNDEkGROUND STORAGE TANS SYSTEM <br /> DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT <br /> Facility Name: W-,1Ay I Inspection Date: ' <br /> Facility Address: /70 f k. 44,0,411A &A#y I City: <br /> Name of Designated UST Operator Conducting Inspection: <br /> International Code Council Certification No.: Expiration Date: t,. a� <br /> Signature: Phone: clM_Vol/ ext. <br /> N =NotApplicable <br /> Item MONITORING PANEL/ALARM HISTORY Yesl No N/A <br /> L4Has <br /> he monitoring system powered on and in proper operating mode? [31 Ll Li <br /> he monitorin s stem not currentl showingan leak alarms? <br /> the Alarm History RepoNlog for the previous month available,and has it been reviewed by the <br /> Designated UST Operator? Attach a co o the alarm histo re ort/lo to this ins ection orm. <br /> each alarm for the revious month been res nded to a ro riatel 7 <br /> for <br /> [, . ..{ ..�... ... . 1i Y .u..�.X:.z` <br /> UST SYSTEM INSPECTION <br /> 5. Are tank-top containment sumps free of water,debris,and hazardous substance? Note:If the answer to Item 4 was"Yes,"skip <br /> to Item 6. Sumps where an alarm has occurred in the past month must be inspected(ja qualified service technician has not responded to, and <br /> proEerly addressed,the cause of the alarm.Documentation ver' Inp4ropriam service should be attached to this"port <br /> esl No <br /> Sump Location: SS ion:L <br /> Sum Location: ny <br /> 6. Are spill buckets containment structures free of water, debris,and hazardous substance? <br /> Yes No NIA Yes No N/A <br /> Tank 1 ID— Tank 41D— <br /> Tank 2 ID— Tank 5 1D— <br /> Tank 3 ID— I Lj I F1 I U I Tank 61D— <br /> 7. Are under-dispenser containment areas free of water,debris,and hazardous substance? <br /> Yes I No I N/A I Yes No N/A <br /> Dispenser— 1/2 Dis enser—9/10 Li <br /> Dispenser—3/4 Di enser— 11112 <br /> Dispenser—516 Dispenser— 13/14 Cl 0 <br /> Dispenser—7/8 1 101 Ll I LJ I Dispenser— 15/16 <br /> 8. Leak detection is properly located within under-dispenser containment. <br /> Y No N/A Yes No N/A <br /> Dispenser—1/2 Dis nser-9/10 <br /> Dis nser-3/4 Dis nser— 11/12 <br /> Dis enser-5/6 Dis nser- 13/14 <br /> Dis enser—7/8 ❑ Dis nser— 15/16 <br /> PAPERWORK INSPECTION Yes No N/A Date Done <br /> 9. Monitoring System Certification was completed within the ast 12 months? tL v$ <br /> 10. Line Leak Detectors were tested/certified within the past 12 months? K El I F1 I '511 s °S <br /> 11. Spill bucket containment structt:re testing completed within the past 12 months? 3 cs <br /> 12. Line rightness testin completed witl,.in therequired time frame? % �t9 <br /> 13. Secondary containment tests cam letea•vithin the required time frame? g t <br /> 14. Enhanced Leak Detection completed within the required time frame? to <br /> 15. Other required testing/maintenance was MmpLtLmd within required time frame? (List test/maintenance items below.) <br /> Describe Test/Maintenance: T _ <br /> Describe Test/Maintenance: <br /> FACILITY EMPLOYEE TELONING I Yepl No I N/A <br /> 16. Have all facilityemployees received the required on-the-job trair,ln within the past ear? <br /> 17. Have all facility employees hired within the past 30 days received thr uired on-the 'ob trainin .? <br /> Note: Explain any"No"answers in the"Comments"section on the following p.:ee. Those issues require corrective action from <br /> the UST owner/operator. <br /> UN-057-12 www.unidocr.org M&GS <br />