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0 <br /> UNDERGROUND STORAGE TANK SYSTEM <br /> DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT <br /> Facility Name: �vl AI C( t Inspection Date: <br /> Facility Address: •3D3a �p. �L City. c C V T 10 L, <br /> Name of Designated UST Operator Conducting Inspection: y �� <br /> C - st <br /> International Cade Council Certification No.: a L1 3 ����Y Expiration Date: _ g hr <br /> Signature: `� e-\ 1t L/\-, Phone: (4cf) U11(--_gjpext. <br /> N/A=Not Applicable <br /> Item MONITORING PANEL/ALARM HISTORY Yes No N/A <br /> I. Is the monitoring stem powered on and in proper operating mode? R ❑ <br /> 2. Is the monitoring system not currently showing any leak alarms? 0 ni ❑ <br /> 3. Is the Alarm History Report/log for the previous month available,and has it been reviewed by the ❑ I ❑ <br /> Designated USTOperator? Attach a copy of the alarm history reportfiog to this inspection orm. <br /> 4. Has each alarm for the revious month been re onded to a riatel ? ❑ L❑ <br /> UST SYSTEM INSPECTION <br /> 5. Are tank-top containment sumps free of water,debris,and hazardous substance? Note.Ifthe 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 /> properly addressed,the cause ofthe alarm.Documentation verif <br /> )dng appropriate service should be attached to this report <br /> Yes I No Yes No <br /> Sump Location: 1210 Sump Location: <br /> Sump Location: I ED 10 °i Sump Location: ❑ ❑ <br /> 6. Are spill buckets containment structures free of water,debris,and hazardous substance? <br /> Yes No N/A Yes No N/A <br /> Tank I ID- ❑ I Tank 4 ID El 0 <br /> - <br /> Tank 21D- EIT❑ I Tank 5 ID- <br /> Tank 3 ID- ❑ ❑ Tank 6 ID- ❑lffi <br /> 7. Are under-dispenser containment areas free of water,debris,and hazardous substance? �8 <br /> Yes I No N/A I s No I N/A <br /> Dispenser- 1/2 ❑ Dispenser-9/10 El I ❑ <br /> Dispenser-3/4 Dispenser-11/12 ❑ ❑ ❑ <br /> Dispenser-5/6 0 r D Dispenser-13/14 ❑ ❑ <br /> Dispenser-7/8 = Dispenser-15/16 ❑ <br /> 8. Leak detection is properly located within under-dispenser containment. <br /> Yes I No I N/A I es No I N/A <br /> Dispenser-1/2 Li ❑ Dispenser-9/10 ❑ 1 ❑ <br /> Dis ser-3/4 Dispenser- 11112 ❑ ❑ I El <br /> Dispenser-5/6 D ❑ Dispenser- 13/14 ❑ ❑ I ❑ <br /> Dispenser 7/8 ❑ Dispenser-15/16 ❑ ❑ ❑ <br /> PAPERWORK INSPECTION Yes No N/A Date Done <br /> 9. Monitoring System Certification was completed within the past 12 months? EM D ❑ <br /> 10. Line Leak Detectors were tested/certified within the past 12 months? ❑ <br /> 11. Spill bucket containment structure testing completed within the past 12 months? El n <br /> 12. -Line tightness testing completed within the required time frame? El ❑ <br /> 13. Secondary containment tests completed within the required time frame? El I <br /> 14. Enhanced Leak Detection completed within the required time frLiame? <br /> 15. Other required testis maintenance was completed within required time frame? List test/maintenance items below.) <br /> Describe Test/Maintenance: El El I D <br /> Describe Test/Maintenance: I Li I ❑ ❑ <br /> FACILITY EMPLOYEE TRAINING Yes No N/A <br /> 16. Have all facility employees received the required on-the-job training within the past year9 ❑ ❑ <br /> 17. Have all facili a la ees hired within the past 30 da s received the required on-the job trainin01 F-1 <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 /> UN457-1/2 tirnvww.unidocs.org 9/26/05 <br />