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UNDERGROUND STORAGE TANK SYSTEM DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT Facility Name: /ji U h 1,t - S��i, L Inspection Date: C' 2 E 2 j '-F�1 d Facility Address: '7 /Q I Dorado � City: � �� Name of Designated UST Operator Conducting Inspection: 1\11k" ra l�f International Code Council Certification No.: jZ/1.3 CI/t._ r' Expiration Date=7ex Signature: Phone: (SIo) N/A=Not Applicable Item MONITORING PANEL/ALARM HISTORY Yes L No N/A 1. Is the monitonn s stem powered on and in proper operating mode? ❑ ❑ 2. Is the monitoring system not currently showing any leak alarms? ❑ ❑ 3. Is the Alarm History Report/log for the previous month available,and has it been reviewed by the ❑ Desi ated UST Operator? Attach a co o the alarm history re ort/lo to this inspection form.) 4. 1 Has each alarm for the nrevious month been res onded to appropriately? ❑ I ❑ UST SYSTEM INSPECTION 5. Are tank-top containment sumps free of water,debris,and hazardous substance? Note:If the answer to Item 4 was "Yes,' slap to Item 6.Sumps where an alarm has occurred in the past month must be inspected if a qualified service technician has not responded to, and properly addressed,the cause of the alarm.Documentation vert in a ro riate service should be attached to this report. Yes No Yes No Sump Location: ❑ Sump Location: El Location: ❑ Sum Location: El6. Ares ill buckets containment structures free of water,debris,and hazardous substance? Yes No N/A Yes No N/A Tank 1 ID– ❑ El Tank 4 ID– El Tank 2 ID– ❑ Tank 5 ID El 1:1 – Tank 3 ID– ❑ Tank 6 ID– 7. Are under-dis enser containment areas free of water,debris,and hazardous substance? Yes No N/A Yes No N/A Dispenser-1/2 ❑ Dispenser-9/10 ❑ ❑ Dispenser–3/4 Dispenser–11/12 ❑ Dispenser–5/6 ❑ ❑ Dis enser–13/14 ❑ Dispenser–7/8 ❑ ❑ Dispenser–15/16 ❑ ❑ 8. Leak detection is properly located within under-dis enser containment. Yes No N/A Yes No N/A Dispenser–1/2 ❑ ❑ Dis enser-9/10 ❑ ❑ Dispenser–3/4 ❑ ❑ Dis enser– 11/12 ❑ Dispenser–5/6 ❑ Dis enser– 13/14 ❑ ❑ Dis enser–7/8 ❑ Dis enser–15/16IRE ❑ PAPERWORK INSPECTION Yes No N/A ZZ Date Done 9. Monitoring System Certification was completed within the past 12 months? ..�� e 10. Line Leak Detectors were tested/certified within the past 12 months? [� ❑ , 11. S ill bucket containment structure testing completed within the past 12 months? ❑ t , 12. Line tightness testing completed within the required time frame? ❑ ❑ 13. Secondary containment tests completed within the required time frame? ❑ ❑ 14. Enhapced Leak Detection completed within the required time frame? 15. Other required testing/maintenance was completed within required time frame? List test/maintenance items below. Describe Test/Maintenance: .$ r'1,T% El 11 14 — 2 S Describe Test/Maintenance: ❑ 31 1,11 log ❑ ❑ FACILITY EMPLOYEE TRAINING Yes No N/A 16. Have all facility employees received the required on-the-job training within the astear? 17. Have all facilityemployees hired within the past 30 days received the required on-the-job trainin .? ❑ Note: Explain any"No"answers in the"Comments"section on the following page. Those issues require corrective action from the UST owner/operator. UN-057-1/2 www.unidoes.org 9/26/05