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`. .or <br /> UNDERGROUND STORAGE TANK SYSTEM <br /> DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT <br /> Facility Name: <br /> 'f�C,Cf7�r/�� Inspection Date: <br /> DUn ti ZIa <br /> Facility Address: <br /> 7 G�• C/�4/[ls.t r Com' S rx of <br /> Name of Designated UST Operator Conducting Inspection: <br /> ArL7ieJ 2 i( <br /> International Code Council Certification No.: Expiration <br /> Signature. Phone: <br /> eb)VW-f/I/ ext. <br /> N/A-Not A cask <br /> Item MONITORING PANEL/ALARM HISTORY tYesNo <br /> 1. Is the monitorin s stem ered on and in proper o modes <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 nated UST or? Attach a co o the alarm history re N! to this itis pion forn <br /> 4. Has each alarm for the p7vious month been responded to riatel ? <br /> UST SYSTEM INSPECTION - <br /> 5. Are tank-top containment sumps free of water,debris,and hazardous substance? Note lfthe ans„er(o Gem tum "Yet"stip <br /> W Item 6.Sumps where an a(nrm has occurred in the puttmomh must be inspected i a qwlykd service technician has not rc <br /> rl addressed the arose the alarm. Docmnentegon ver rude service should be aaarhed to this m st d(o. and <br /> Yes Ne ,4-_ Yes No .. <br /> Sum Location: Sum Location: <br /> S Location: a'+'1' S Location: <br /> 6. Are ill buckets comainnteni structures free of water,debris,and hazardous substance? <br /> Y No N/A Yes No N/A <br /> Tank ] 1D- Tank 4(D- <br /> Tank <br /> 21D- Tank 5 ID- <br /> Tank 3 ID- Tank 61D- <br /> 7. Are under-di nser containment areas fire of water debris and hazardous substance? <br /> Yes No N/A <br /> Di r- In Y 11 es No N/A Dis enser-9/10 <br /> nser-3/4 Dis nser- 11/12 <br /> Dis ser-5/6 Di nser- 13/14 <br /> Disperim-7/8 Dis nser-15/!6 <br /> 8. Leak detection is ro rt located within under-dis nser containment. <br /> Yes No N/A Yes No N!A <br /> -j«f.3 •me r _ - Dis nser-9/10 <br /> Dis enser-5/6 Di enser- 13/14 <br /> Dispenser-7/8 - z- Di enser= 15/16 <br /> System C <br /> PAP WORT(INS ION Yes No N/A Dae ne <br /> 9'• >\fit+aitorin ertiftcatiod was completed within the r-12 months? <br /> 10. Lith Leak Detectors were test3il/certified within the.past 12 months? 8 <br /> ii •li bucket cOn"TiTtett structure testin com leted within the past 12 months? <br /> 12. Line ti a leted within therequired time Game? t <br /> 13. containment tests completed within the required time frame? b <br /> 14. Enhanced Leak Detection completed within the reguired time frame? <br /> I5. Other died matin maintenance was completed within required time frame? List tesf1maintenance items elow. <br /> Describe Test/Maintenance: <br /> Describe Test/Maintenance: <br /> Li <br /> FACILPTY EMPLOYEE TRAINING Y No N/A <br /> 16. Have all ficili em to nes received the required on-the-job trainingwithin the ear? <br /> u I <br /> 17. 1 Have all facility employees hired within the past 30 days received the required on-the_' trainee .? <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.e57.1rz ww.v.nNn,u•<."A ---- <br />