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UNDERGROUND STORAGE TAIL{ SYSTEM <br /> DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT <br /> Facility Name: w1'eY loktrw ,of Inspection Date: <br /> Facility Address: /7, t4/4,t fu 44eY City: 9C`�aN 1 <br /> Name of Designated UST Operator Conducting Inspection: rc /o.-AV C <br /> � �-,/e-International Code Council Certification No.: cJ !�'� Expiration Date: <br /> Signature: 1 Phone: 4/1,1.0/1 ext. <br /> N/A-NotAPDWficxb1e <br /> Item MONITORING PANEL/ALARM HISTORY YA. No N/A <br /> 1. Is the monitoring system powered on and in proper operating mode? <br /> 2. is the monitoring system not currently showing any leak alarms? <br /> 3. Is the Alarm History Report/log for the previous month available, and has it been reviewed by the <br /> Designated UST Operator? Attach a copy o the alarm history report/logreporillog to this ins ection orm. <br /> 4. Has each alarm for the revious month been res onded to ro riatel ? <br /> UST SYSTEM INSPECTION <br /> 5. Are tank-top containment sumps free of water, debris,and hazardous substance? Note:Ifthe answer to item 4 was "Yes,"skip <br /> to Item 6. Sumps where an alarm has occurred in the past month must be inspected iia qualified service technician has not responded to, and <br /> properly addressed,the cause of the alarm.Documentation ver i n a ro riate servlce should be attached to isreport. <br /> Yes No Yes No <br /> Sump Location: Sum Location: <br /> Sump Location: I Lj I Lj Sump Location: 10 1 <br /> 6. Ares ill buckets containment structures free of water,debris,and hazardous substance? <br /> Yes No N/A 1 Yes No N/A <br /> Tank I ID— 141D-Tank <br /> Tank 2 ID— Tank 5 1 D Li I <br /> — <br /> Tank 3 ID— Tank 61D— <br /> 7. Are under-dispenser containment areas free of water,debris,and hazardous substance? <br /> Y No N/A Ye No N/A <br /> Dispenser— 1/2 Dispenser—9/10 <br /> Dispenser—3/4 Dispenser— 11/12 ETI 1j # <br /> Dispenser—5/6 Dispenser— 13/14 <br /> Dispenser-7/8 Dispenser— 15/16 <br /> S. Leak detection is properly located within und r-dispenser containment. <br /> Yes I No I N/A I Vesj No I N/A <br /> Dispenser— 112 Dispenser—9/10 <br /> Dispenser—3/4 Dispenser— 11/12 <br /> Dis enser-5/6 Dis enser— 13/14 <br /> Dis enser-7/8 Dis enser- 15/16 <br /> PAPERWORK INSPECTION Yes No JNIA Date Done <br /> 9. Monitoring System Certification was completed within the past 12 months? Li I Ej S1 124 <br /> 10. Line Leak Detectors were tested/certified within the past 12 months? Li I Li ib, <br /> 11. Spill bucket containment structure testing completed within the past 12 months? Li I Lit <br /> 12. Line tightness testing completed within the required time frame? <br /> 13. Secondary containment tests completed within the required time frame? (per <br /> 14. Enhanced Leak Detection completed within therequired time frame? t s4. <br /> 15. Other required testingimaintenance was completed within required time frame? is, test/main[enanee items below) <br /> Describe Test/Maintenance: <br /> Describe Test/Maintenance: <br /> IR <br /> FACILITY EMPLOYEE TRAINING Yesj No I N/A <br /> 16. 1 Have all ilit employees received the required on-the-job training within the past ear? <br /> 17. 1 Have all facility employees hired within the past 30 days received the required 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 /> UN-057.1/1 www.unidms.org 9/26/05 <br />