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UNDERGROUND STORAGE TANK SYSTEM <br /> DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT <br /> Facility Name: N A2KC� £ Inspection Date: / a <br /> Facility Address: City <br /> S Get rlA 2 Gs�A'f : S YUC.-7e J <br /> Name of Designated UST Operator Conducting Inspection: AZJie%1 re e4i)£ <br /> International Code Council Certification No.: -6-9A-51f._V` Expiration Date: <br /> Signature: Phone: ( ext. <br /> N/A=Not Applicable <br /> Item ——MONITORING PANEL/ALARM HISTORY Yes No N/A <br /> 1. Is the monitoring system powered on and in proper operating mode? 17 <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 of the alarm history report/logreportllog to this ins ection orm.) <br /> 4. Has each alarm for the previous month been responded to appropriately? <br /> UST SYSTEM INSPECTION <br /> 5. Are tank-top containment sumps free of water,debris,and hazardous substance? Note:If the answerto liens 4 was"Yes,"Skip <br /> to hent 6. Sumps where an alarm luu occurred in dw past mmmth must be inspected if a qualified service technician Jus,not responded to, and <br /> properly addressed,use cause of the alarm.Dorumentation vera in a m nate service should be attarlied to this report. <br /> Yes I No I I Yes No <br /> -Sump Location: I Lj I Lj I I Sump Location: I Li Li <br /> Sump Location: I LJ I I I I I Sump Location: 1111 L <br /> 6. Ares ill buckets(containment structures)free of water,debris,and hazardous substance? <br /> Yes No N/A Yes No N/A <br /> Tank 1 ID- Tank 4 ID L1 0 Li <br /> - <br /> Tank 2 ID- I ff I Lj I Li Tank 5 ID- <br /> Tank 3 ID- Tank 61D- <br /> 7. Are under-dispenser containment areas free of water,debris,and hazardous substance? <br /> Yesj No I N/A I Yes I No I N/A <br /> -Dispenser- 1/2 Dispenser-9/10 <br /> -Dispenser-3/4 Dis enser- 11/12LJ I Li I Li <br /> -Dispenser-5/6 Dis enser- 13/14 <br /> Dispenser-7/8 0 1 LJ I Dispenser-15/16 <br /> 8. Leak detection is properly located within under-dispenser containment. <br /> YesA No I N/A F I Yesj No I N/A <br /> Dispenser- 1/2Dis enser-9/10i Li <br /> Dispenser-3/4 Dispenser- 11/12 Li <br /> Dispenser-5/6Dis enser- 13/14 <br /> Dispenser-7/8 Dis enser- 15/16 <br /> PAPERWORK INSPECTION Ye5j No I N/A I Dae Done <br /> 9. Monitoring System Certification was completed within the past 12 months? I U I b / o 6 <br /> 10. Line Leak Detectors were tested/certified within the past 12 months? / <br /> 11. Spill bucket(containment structure)testing completed within the past 12 months? 10 b1s, <br /> 12. Line tightness testing completed within the required time frame? G <br /> 13. Secondary containment tests completed within the required time frame? I lial <br /> 14. Enhanced Leak Detection completed within the required time frame? <br /> 15. Other required testing/maintenance was completed within required time frame? (List test/ataIt,ten ance items below.) <br /> Describe Test/Maintenance: <br /> Describe Test/Maintenance: <br /> FACILITY EMPLOYEE TRAINING Yes No N/A <br /> 16. Have all facilit employees received the required on-the-job trainingwithin the as[ ear? Li <br /> l7. Have all facilit em to ees hired within the ast 30 da s received the r uired on-the-'ob training.? <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 /> UN457-1/2 www.unidocaorg 9/26/05 <br />