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UNDERGROUND STORAGE TANK SYSTEM <br /> DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT <br /> Facility Name: TVyq yt__ (^. I 3 Inspection Date: 021M. <br /> Facility Address: � E 19 City: <br /> Name of Designated UST Operator Conducting Inspection: <br /> International Code Council Certification No.: �q Expiration Date: <br /> Signature: Phone: (gjv).;q_ \\ ext. <br /> N/A-NOtArAleabl. <br /> Item MONITORING PANEL/ALARM HISTORY Ye o NIA <br /> 1. Is the monitorin s stem—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 repor0og to this inspection onn. <br /> 4. Has each alarm for the revious month been responded to ro nate/ ? <br /> UST SYSTEM INSPECTION <br /> 5. Are tank-top containment sumps free of water,debris,and hazardous substance? Nore:l/the answer to hen,4 wm"Yes."Skip <br /> to hem 6.Sumps where rut olamt has occurred in the pat(month must he inspected if a qualRed service technician has not responded tm,and <br /> ro er addressed.the cause o the alarm.Documemadon vert in a ro riareaerviceshould he auachedt Nitro rt. <br /> Yes No Yes No ->. <br /> Sum Location: Sum Location: 11 r <br /> Sum Location: Sum Location: - <br /> 6. Are s ill buckets(coat ' ent structures free of water debris and hazardous substance? <br /> Yes Yes No N!A <br /> Tank 1 ID— 'ITank 4 ID— <br /> Tank 2 ID— Tank 5 ID— <br /> Tank 3 ID— Tank 6 ID— <br /> 7. Are under-dispenser containment areas free of water,debris and hazardous substance? <br /> Y No N/A Yes No N/A <br /> Dis enser-1/2 Dispenser-9/10 1 Lk <br /> Dis eraser-3/4 ❑ Dispenser-11112 ❑ <br /> Dis enser-5/6 Di enser—13/14 <br /> Dis eraser-7/8 Dispenser—15/16 <br /> 8. Leak detection is ro erl located within under-dis ensu containment. <br /> Yes No N/A Yes No N/A <br /> Di ser-1/2 Dis eoser-9110 El LJ Ld <br /> Dispenser—3/4 Di ensu-11112 <br /> Dispenser—516 Dis eraser-13114 <br /> Dis enser-7/8 Dispenser—15116 <br /> PAPERWORK INSPECTION Yes No N/A Date Done <br /> 9. 1 Monitoring System Certification was completed within the past 12 mouths? ' t <br /> 10. Line Leak Detectors were tested/certified within the past 12 months? <br /> 11. 1 S ill bucketcontainment structure testingcompleted within the past 12 months? t' <br /> 12. Line ti mess testin completed within the required time frame? <br /> 13. Secondary containment tests completed within the required time frame? <br /> 14. Enhanced Leak Detection corn leted within the required time Game? <br /> 15. Other re uired testing/maintenance was corn leled within required time frame? (List test/maintenance items below. <br /> Describe TesUMaintenance: <br /> Describe Test/Maintenance: Li <br /> FACILITY EMPLOYEE TRAINING A Wal o I N/A <br /> �- 1 16. Have all facility employees received the 'ed on-the-job training within the past ear? <br /> 17. 1 Have all facility em to ees hired within the esdays received the required on-the=oh trainin :? <br /> Note: Explain any"No"answers in the"Comments" <br /> 30 section on the following page.Those issues require corrective action frot <br /> the UST owner/operator. 6' r�, • -" <br /> UN-057.1/1 einr.onidocs.org t"•. y t� 9/3W1 <br /> APR 2 2 2016 <br />