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eft / X) 1 //`V, //0,W A3C, UNDERGROUND STORAGE TANK SYSTEM DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT Designated I,acility Name: Ad Inspection Date: I J Facility Address:47 City: Facility sjj Name of Designated UST Operator Conducting Inspectio, International Code Council Certification o.: ~^ 9P Expiration Date: Signature- Phone: 09=7442x&Uaj N/A=Not A ficable Item MONITORING PANEL ALARM HISTORY Yes No N/A 1. is the m-;s stem owered on and in proper operati D 2. Is the mo—f-j——c'" not currently showing_at leak alarms? FE 3. is the Alarm History ReportJlog for the previous month available,and has it been reviewed by the � 0 El Desi nated UST Operator? (Attach a copy.of the alarm history reportl7o.to this inspectionfiorm.) 4. Has each alarm for the previous month been responded to a ro a lately? 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, Ail? to Item 6. Sunips where an alarm has occurred in the past inonth must be inspected if a qualified service technician has not responded to,and =01�r-�l�.addi-essed,th,ecaiiseofthealami.Docuiient nveridnga opriate service should be attached to this report. Yes NO Yes No N Sump Location: _X ❑ Sump Location: Q El Sump Location: ❑ Sump Location: 6. Are spill buckets, containment structures)free of water debris,and hazardous substance? Yes No N Yes No N/A Tank I ID- Q ❑ Tank 4 ID- Tank 2 ID- Tank 5 ID- Tank 3 ID- ❑ El 7. Are under-dispenser containment areas free of water,debris,and hazardous substance? /]4A Tank 4 ID- Tank 5 ID- Tank 6 ID- FT Yes I Na I N/A Yes No N/A I Dispenser-1/2 F-I F1 Dispenser-9/1.0 I LJ Dispenser-3/4 Dis enser-11/12 -5/6 Dispenser Dispenser 13/14 ❑ Dispenser-7/8 Lj I D I D Dispenser-15/16 8. Leak detection is property located within under-dispenser containment. Yes I No N/A I Yes No N/ Dispenser-1/2 Dispenser-9/10 D El LJ Dispenser-3/4 Dispenser-11/12 R F1 F Dispenser-5/6 El F] ❑ Dispenser-13114 ❑ Dispenser-7/8 ❑ -Dispenser-15/16 PAPERWORK.INSPECTION Yes No N/A Date Done 9. Monitoring System Certification was completed within the past 12 months? Jr I El F] 1A-11nQ_(e_ 10. Line Leak Detectors were tested/certified within thepast 12 months? El I Q F] 11, Spill bucket(containment structure)testinR completed within the past 12 months? /,6-1 0/_ j5 F12. Line tightness testing corn feted within the required time frame? 14 3. El Il- 2 13. Secondary containment tests completed within the required time frame? F 14. Enhanced Leak Detection completed within the required time frame? _ 15. 1 Other required testing/maintenance was completed within required time frame? (List test/maintenance items below.) Describe Test/maintenance: I Lj I " I Lj Describe Test/Maintenance: I Ej I L1 ❑ FACILITY EMPLOYEE TRAINING Yes No N/A 16. Have all facility employees received the required on-thejob trainin within the past year? 17. Have all facilitX ern2loyees hired within the past 30 da s received the required on-thejob traininS.? ❑ Note: Explain any"No"answers in the"Comments"section on the following page.Those issues require corrective action from the UST owner/operator. IIN-057-1/2 www.oiiiidoes.org 9126/05