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UNDERGROUND STORAGE TANK SYSTEM <br /> DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT <br /> Facility Name: n 72 /W f/Ck f z <br /> Inspection Date: 7 It I <br /> Facility Address: 7� eV �Rx,7 City: S7��.,tyyj.J <br /> Name of Designated UST Operator Conducting Inspection: <br /> International Code Council Certification No.: S- _ Expiration Date: ijl7/e)(5 <br /> Signature: Phone: ,f-0p/_ext. <br /> N!A=Not Apolkable <br /> Item MONITORING PANEL/ALARM HISTORY Yesl No I 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 USTOperator? Attach a copy of the alarm history report/logreporillog to this ins ection orm. <br /> 4. Has each alarm for the previous month been responded to appropriately? <br /> of -17 <br /> _. <br /> UST SYSTEM INSPECTION <br /> 5. Are tank-top containment sumps free of water,debris,and hazardous substance? Note:ff the answer Infirm I was )es, <br /> skip <br /> to Item 6. Sumps inhere an alarm has occurred to the past month must be inspected f a qualified service technician has not responded trt addressed.the cause o the alarm.Documentation twri ,in a ro riate service should he attached to this re rt.Yes No Sum Location: Sum Location: <br /> Sum Location: Sum Location: I Li I Li6. Ares ill buckets containment structures free of water,debris,and hazardous substance? <br /> Yes No <br /> Tank I ID- Tank 4 ID- <br /> Tank 2 ID- I LJ I LJ I L Tank 5 ID Lj <br /> - <br /> Tank 3 ID- I Lj I Lj I Lj j Tank 6 ID- <br /> 7. Are under-dispenser containment areas free of water,debris,and hazardous substance? <br /> Yes I No N/A Yes No N/A <br /> Dispenser-1/2Dis enser-9/10 MLI <br /> Dispenser-3/4 Dis enser- I I/12 <br /> Dispenser-5/6 Dis enser- 13!14 <br /> Dispenser-7/8 1 LI I LJ I LJ I Dispenser- 15/16 <br /> 8. Leak detection is properly located within under-dispenser containment. <br /> Yes No N/A Yes No N/A <br /> Dis enser- I/ Dispenser-9110 <br /> Dispenser-5/6 Lj Dispenser- 13/14 Li Li U <br /> Lj Dispenser-' 15/16 <br /> PAPERWORK INSPECTION Yes No I N/A I Date Pone <br /> 9: Monitoring stem Certification was coin leted'within thepast-12 months? I El I H110 <br /> 10. Line Leak Detectors were test6d/certified within the. ast 12 months? I Li b// <br /> Tl,_ Spill bucket containment structure testing completed within the past 12 months? <br /> 12. Line tightness testing completed within the required time frame? <br /> 13. Secondary containment tests completed within the required time frame? 10 V1 I i io <br /> 14. Enhanced Leak Detection completed within the required time frame? <br /> s /1 66 <br /> 15. Other required testis maintenance was completed within required time frame? (List test/maintenance items below. <br /> Describe Test/Maintenance: <br /> Describe Test/Maintenance. El El <br /> ,...FACILITY EMPLOYEE <br /> OYEE TRAINING - Yes No N/A <br /> 16. Have all facility employees received the required on-the job trainingwithin the past year9 �Lw 10 <br /> 17. Have all facility employees hired within the past 30 days received the required on-the-job 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 /> UN-057-1/2 ...unidocs.org 926M <br />