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.1 <br /> UNDERGROUND STORAGE TANK SYSTEM <br /> DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> A�l�P7pcA� 6 <br /> Facility Address: 1,7A <br /> 6--), <br /> Name of Designated UST Operator conducting Inspection: �L7i�y /.��D <br /> Intonational Code Council Certification No.: <br /> . S,2 Expiration Date: <br /> Signature s o Phone: <br /> // 71aD <br /> ext. <br /> ItetaN/A-Not A bio <br /> MONITORING PANEL/ALARM HISTORY Yes No <br /> I. Is the monitorin System powered on and in r r operating mode? N/A <br /> 2. Is the monitoring System not currently showing any leak alarms? <br /> J. Is the Alarm History Report/log for the previous month available,and has it been reviewed by the <br /> Desi ated UST Operator9 Attach a copy o the alarm history re t/ to this Ars ion <br /> 4. Has each alarm for the mvious month been res nded to a iatcl. . <br /> UST SYSTEM INSPECTION <br /> 5. Are tank-top containment sumps free of water,debris,and hazardous substance? Nae:0he ann,,rr to Item!was -Yes•"sap <br /> to Item 6. Sump,white on at.— has occurred in the port month must be inspected f a gtm/ifled service technician has not responded to. and <br /> rl addreued the rm du a/a wt.Docwnemauo, ver irne service rhmtld be attached to this rc <br /> poH <br /> Yes Ya No <br /> Sum Location , O"` <br /> S Location. ':.,!' Sump Location: LJ <br /> SM2 Location: <br /> 6. Are s ill buckets eontainmant structures)free of water debris,and hazardous substance? <br /> Yes No N/A Yes No N/A <br /> Tank 1 ID- Tank 4 ID- <br /> Taak 2 ID- Tank 5 ID- <br /> Taak 3 ID- Tank 6 ID- <br /> 7. Are under-dispenser containment areas fnx of water,debris,and hazardous substance? <br /> Yes No N/A Yes No N/A <br /> Di "ser- 12 Dis riser-9/10 <br /> Dispenser-3/4 Dis enser- 11/12 <br /> Dis ser-56 Dis nser- 13/14 <br /> Drs -718 Di nser-15/16 <br /> 8. Leak detection is ro rl located within under-ds riser containment. <br /> Yes No N/A Yes No N/A <br /> Di ser- Dis enser-9/10 <br /> 3► <br /> Dispenser-5/6 Di enser- 13/14 <br /> Dis nser-7/8-• - -sLi <br /> Di enser ' I5/16 <br /> PAP, RIC INSP9CT10N Yes No /A Date Done <br /> �: i4kmitor n System Certifica(iud was leted within the asr 12 months? <br /> 10. Lane Leak Detectors were teiUdIcerrified within the-post 12 months? <br /> T1, VM oueket e0meimnent structure <br /> testinx completed within the past 12 months? <br /> 12. Line ti Hess testing EaMleted within the.required time frame? o <br /> 13. containment tests completed within the required time frame? <br /> 14. Enhanced Leak Detection cont leted within the Tguired time frame? <br /> I5. Cytherrequirea testis maintenance was completed within required time frame? List test/maintenance items below. <br /> Describe Test/Maintenance: <br /> Describe Test/Maintenance: <br /> . FACMXrY EMPLOYEE TRAINING Yes No N/A <br /> 16. Hnve ell facili em Io hes received the ' ed on-the trainingwithin the past ear? <br /> 17. Have all Cacili em to hes.hired within the 30 da received the required on-the-job 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 /> t1N4"-12 <br />