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UNDERGROUND STORAGE TANK SYSTEM DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT Facility Name: ,A) G1�� Inspection Date: 2- Facility - _ '1n� 1=n e , � 1F ( 1�- FacilityAddress: �v3 Z w a U4(to City �' L�� Name of Designated UST Operator ConductinInspection: C=, International Code Council Certification No.: !j .l-l S _ v, ` Expiration Date' I I - - C' Signature: C L U Phone: (;Lcq) 14 L 6' 1 t,ext. N/A a Not AppHeabb Item MONITORING PANEL/ALARM HISTORY Yes No I N/A 1. Is the monitoring powered on and in proper operatingmode? 2. Is the monitoring not currently showni 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 Attach a copy o the alarm history!Vortft to this i norm. 4. Has each alann for the ous month been to atel UST SYSTEM INSPECTION 5. Are tank-top containment sumps free of water,debris,and hazardous substance? Note.Jf the answer to Item d 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 qf1he alarm.Dbcumewmios a service shadd be attached to this repwt Yes No Yes No Sump Location: Sump Location: Sump Location: Sump Location: 111 ❑ 6. Are spill buckets containment structures free of water,debris,and hazardous substance? Yes No N/AI Yes No I N/A Tank l ID- hd I El I ❑ I Tank 4 ID- Tank 2 ID.- Vi I H 1 Tank 5 ID- f-E] 0-103- Tank 3 11)- FffrETank 6 ID- ❑ 7. Are under-dispenser containment areas free of water,dfts,and hazardous substance? YesI No NIA Yes I No I N/A Dispenser-1/2 ❑ C1 Di -9/10 E I I ❑ Di -3/4 Di -11/12 IT §Lj Dispenser-5/6 ❑ ❑ Di -13/14 4 ❑ Dispenser-7/8 ❑ Di -15/16 8. Leak detection is properly located within under-dispenser containment. Yes NoI NIA Yes I No N/A Di ser-1/2 Dispenser—9/10 ❑ Di —3/4 ❑ sex-11/12 ° ❑ ❑° Dispenser-5/6 ❑ -13/14 Fn Di ser 7/8 -15/16 ❑ ❑ Di PAPERWORK INSPECTION Yes No NIA Date Done 9. Monitoring System Certification was completed within the past 12 months? V1 1 0 ❑ 10. Line Leak Detectors were tested/certified within the past 12 months? I El El 11. Spill bucket containment structuretesting completed within the past 12 months? 0 El 12. -Line ti tnesstesting completed within the required time frame? ❑ 13. ary c:ontaimnent tests completed within the required time frame? 14. Enhanced Leak Detection completed within the required time frame? 14 El I 15. Other iced testinghnaintenance was completed within required time frame? List test/mainten21 items below. Describe TesdMaintenance: Describe Test/Mamtenance FACILITY EMPLOYEE TRAINING Yes I No I N/A 16. Have all facility 1 receival the required on-the-job training within the past year9 010 0 117. Have all facil"l!X M!pLo=hired within the 30 days received the red on-the-"ob trainin .? ❑ Note: Explain any"No"answers in the"Comments"section on the following page.Those issues require corrective action from the UST owner/operator. UNA57-12 www.unide s org 926/05