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UNDERGROUND STORAGE TANK SYSTEM DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT Facility Name: l j / F S� l Inspection Date: �'V D ,'a 32—CI Facility Address: 7/3N /. I Doan City: � o ek+6Name of Designated UST Operator Conducting Inspection: J�J�k� (fa l�I International Code Council Certification No.: 2/1.31 C,/�__ ` , 1' `I Expiration Date: d o�6 �S Signature: T V Phone: (Slo )67I,W)7 ext. N/A= o(AimUcable Item MONITORING PANEL/ALARM HISTORY Yes No N/A 1. Is the monitoring system powered on and in proper operating mode? ❑ El 1:12. Is the monitoringsystem not currentlyshowinganleak alarms? ❑ ❑ 3. Is the Alarm History Report/log for the previous month available,and has it been reviewed by the ❑ Designated USTOperator? Attach a copy of the alarm history report/logreportfiog to this inspection orm. 4. Has each alarm for theprevious month been res onded to appropriately? ❑ ❑ 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,"slip 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 ve!j&n&gppLMriate service should be attached to this report. Yes No Yes 0 Sump Location: -7 ❑ Sump Location: t. ElSum Location: :9 ❑ Sump Location: ❑ 6. Ares ill buckets containment structures free of water,debris,and hazardous substance? Ye No N/A I Yes No N/A Tank 1 ID— ❑ Tank 4 ID EJ 0 — Tank 21D— ❑ Tank 5 ID— Tank 3 ID— ❑ ❑ E ElTank 6 ID— El EJ ❑ 7. Are under-dispenser 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 El 1:1 Dispenser—5/6 ❑ ❑ Dispenser—13/14 gso Dispenser—7/8 ❑ ❑ Dispenser—15/16 8. Leak detection is properly located within under-dis enser containment. Ye No N/A Dis enser— 1/2 ❑ ❑ Dis enser-9/10 EEIIDis enser-3/4 ❑ ❑ Dis enser-11/12 Dis enser—5/6 ❑ Dis enser— 13/14 Dis enser—7/8 Dis enser—15/16PAPERWORK INSPECTION Yes No N/A Date Done 9. Monitoring System Certification was completed within the past 12 months? ❑ Q _i 10. Line Leak Detectors were tested/certified within the past 12 months? ❑ ,, 11. Spill bucket containment structure testing completed within the past 12 months? ❑ / 12. Line tightness testing completed within the required time frame? ❑ ❑ -07 13. Seconda containment tests completed within the required time frame? ❑ 14. Enhapced Leak Detection com leted within the required time frame? 15. Other required testing/maintenance was completed within required time frame? List test/maintenance items below. Describe Test/Maintenance: P 1� Ll Describe Test/Maintenance: ❑ ❑ ❑ FACILITY EMPLOYEE TRAINING Yes No 7,q 16. Have all facilityemployees received the required on-the-job trainingwithin the past ear? ❑ 17. Have all facilityemployees hired within the past 30 days received the required on-the-'ob 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