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0 i <br /> UNDERGROUND STORAGE TANK SYSTEM <br /> DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT <br /> Facility Name: � i Inspection Date: _ <br /> Facility Address: ��, a L w cA ki-t,L Clty z ( Z t <br /> Name of Designated UST Operator Conducting Inspection: n- <br /> International Code Council Certification No.: a7 L` 3 C._ Expiration Date: ,` ,._ C? <br /> Signature: Phone: �t, <br /> �1� a bG'Sl'�ext. <br /> N/A=Not Appikable <br /> Item MONITORING PANEL/ALARM HISTORY Yes No I N/A <br /> 1. Is the monitoring stem powered on and in proper operating mode? R F1 I El <br /> 2. Is the monitoring system not currently showing any leak alarms? ❑ <br /> 3. Is the Alarm History Report/log for the previous month available,and has it been reviewed by the ❑ ❑ <br /> Designated USTOperator? Attach a copy of the alarm history reportllog to this ins ection orm. <br /> 4. Has each alarm for theprevious month been onded to a atel ? <br /> UST SYSTEM INSPECTION <br /> 5. Are tank-top containment sumps free of water,debris,and hazardous substance? Note:If the answer to Item 4 was "Yes,"skip <br /> 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 <br /> property addressed,the cause o the alarm.Documentation ve?7fpng a r riate service should be attached to this report <br /> Yes No Yes No <br /> Sump Location: ❑ -Sump Location: ❑ <br /> Sump Location: ❑ Sum Location: <br /> 6. Are ill buckets containment structures free of water,debris,and hazardous substance? <br /> Yes No NIAYes No N/A <br /> Tank i ID- ElTank 4 ID- ❑ El <br /> Tank 2 ID- El IT] Tank 5 ID- n El ElED <br /> Tank 3 ID- ❑ ❑ Tank 6 ID- ❑ ❑ ❑ <br /> 7. Are under-dispenser containment areas free of water,debris,and hazardous substance? <br /> Yes I No IN/A- I es I No I N/A <br /> Dispenser- 1/2 ❑ Dispenser-9/10 ❑ <br /> Dispenser-3/4 ❑ Dispenser-11/12 <br /> ❑ <br /> Dispenser-5/6 El I U Dispenser-13/14 ❑ 1 El I ❑ <br /> Dispenser-7/8 ❑ 01 Dispenser-15/16 ❑ 10 <br /> 8. Leak detection is properly located wi -dispenser containment. <br /> Yes No I N/A I Yes I No I N/A <br /> Dispenser-1/2 ID ❑ I nDispenser-9110 "DateDonoe <br /> Dispenser—3/4 Dispenser—11/12 <br /> Dispenser-5/6 ❑ Dispenser-13/14 <br /> Dispenser 7/8 Dis ser-15/16 PAPERWORK INSPECTION Yes No N/A <br /> 9. Monitonn System Certification was completed within the past 12 months? ❑ <br /> 10. Line Leak Detectors were tested/certified within the past 12 months? ❑ I ❑ <br /> 11. Spill bucket containment structure testing completed within the past 12 months El I ❑ <br /> 12. -Line tightness testing completed within the required time frame? ❑ ❑ <br /> 13. Secondary containment tests completed within the required time frame? ❑ <br /> 14. Enhanced Leak Detection completed within therequired time frame? El I ❑ <br /> 15. Other required testing/maintenance was completed within required time frame? List tesilmaintenance items below. <br /> Describe Test/Maintenance: 1010101 <br /> Describe Test/Maintenance: I ❑ ❑ ❑ <br /> FACILITY EMPLOYEE TRAINING Yes I No I N/A <br /> 16. Have all facility employees received the required on-the-job training within the past ear? 19 1111 0: <br /> 17. Have all facili Lmpl2yees hired within the.past 30 days received the Leguired on-th!-job trainin .? <br /> Note: Explain any"No"answers in the"Comments"section on the following page.Those issues require corrective action from <br /> the UST owner/operator. <br /> UN-057-1/2 www.unidocs.org 9/26105 <br />