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UNDERGROUND STORAGE TANK SYSTEM DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT Facility Name: o A JJ / � 1 Inspection Date: • �'V i —S �Io pec0 Facility Address: 7/3 N I Domdo City: Name of Designated UST Operator Conducting Inspection: NO<" Pa J Q'I International Code Council Certification No.: jZ/t.3�C�/t._ Expiration Date: d oJ6 fl S Signature: "r Phone: (Slp)4 77-f 46 7 ext. N/A=Not Apphcable Item MONITORING PANEL/ALARM HISTORY Yes2NoN/AI. Is the monitorin s stem owered on and in ro er o eratin mode?2. Is the monitorin s stem not currentl showin an leak alarms?3. Is the Alarm History Report/log for the previous month available,and has it been reviewed by the Desi ated UST O erator? Attach a co o the alarm histo re ort/lo to this ins ection orm.4. Has each alarm for the revious month been res onded to a ro riatel 9 UST SYSTEM INSPECTION 5. Are tank-top containment sumps free of water,debris,and hazardous substance? Note:Ifthe answer to Item 4 was"Yes,"skip 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 o the alarm.Documentation veri in a ro riate service should be attached to this report. Yes No Yes No Sum Location: 7 ❑ Sum Location: L ❑ Sum Location: Sum Location: ❑ 6. Are s ill buckets containment structures free of water,debris,and hazardous substance? Yes No N/A Yes No N/A Tank 1 ID— �"7 ❑ Tank 41D— ❑ ❑ ❑ Tank 2 ID— ( ❑ Tank 5 ID— ❑ ❑ Tank 3 ID— j_ ❑ Tank 6 ID— ❑ ❑ 7. Are under-dispenser containment areas free of water,debris,and hazardous substance? 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 ❑ Dispenser—7/8 ❑ ❑ Dis enser—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 ❑ ❑ Dispenser—I 1/12 Dispenser—5/6 ❑ Lj Dispenser— 13/14 ❑ ❑ Dispenser—7/8 Dis enser—15/16 ❑ ❑ PAPERWORK INSPECTION Yes No N/A Date Done 9. Monitoring S stem.Certification was completed within the past 12 months? 10. Line Leak Detectors were tested/certified within the past 12 months? i 1. Spill bucket containment structure testing completed within the past 12 months? 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? is test/maintenance items below. Describe Test/Maintenance: M1 Describe Test/Maintenance: ❑ ❑ ❑ FACILITY EMPLOYEE TRAINING Yes No N/A 16. Have all facility employees received the required on-the-'ob training within the past ear? 17. Have all facility employees hired within the past 30 days received the required on-the-job training.? ❑ 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